The impact of a home based education and self management programme for patients with chronic back pain after completion of a multidisciplinary pain management programme

Chronic back pain of non-cancer origin and its associated hardship and suffering is a major problem for people with pain. Such individuals may experience consequential distress, disability and disadvantage, and the communities in which they live may also face many attendant problems. The realisation, in the 1970s, of a fundamental difference between acute pain and the chronic pain experience has led to a proliferation of treatment and management techniques for the patient with chronic pain. Despite promising early benefits from these techniques many patients experience relapses and continue to struggle with chronic pain. This study evaluates a treatment approach designed to maintain and extend initial treatment gains by acknowledging chronic pain as a condition similar to other chronic illnesses, which require regular follow up and maintenance. A randomised controlled trial was used to evaluate a home based, education and self-management programme. The home based programme was provided as a follow-up intervention in the first year following patients' participation in a 4 week back pain management programme. Sixty patients with a diagnosis of chronic back pain who had completed a 4 week hospital based, out-patient back pain management programme based on cognitive-behavioural and functional restoration principles, participated in the study. Immediately after completion of the established pain management programme, patients were randomly allocated into 1 of 3 groups: experimental, placebo or control. The experimental group received a mailed out educational and self-management programme reinforcing the pain management techniques taught during the 4- week pain management programme. The placebo group received mail-outs of generic health promotion material. The control group received the standard follow-up associated with the existing programme. After 3 months and at the end of 12 months all patients were invited back to the hospital where they completed three widely used outcome questionnaires. The Pain and Impairment Relationship Scale (PAIRS), The Pain Disability Index (PDI) and The Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), evaluating their perceived functional disability, and their beliefs and attitudes about their pain. Patient responses were analysed using multi-variate and linear mixed effects analyses. Patient response rates diminished over the 12 month follow-up period. This was impacted on by administration difficulties with the data collection. For this reason analysis of data concentrated on the time periods from pre-programme to 3- month follow-up, with only descriptive statistics being possible for the final follow-up period at 12 months. However analysis of the data indicated some interesting trends. At 3 months, responses to the PDI, the OLBPDQ and the PAIRS questionnaires, indicated that patients in the placebo group scored significantly better than the control group, and that patients in the experimental group had better (but not significant) results in comparison with the control group, suggesting that the provision of ongoing support as an addition to the original programme enhanced their maintenance of physical gains and improved beliefs about their pain and disability. Increased age, unemployment, being on a pension, being without a partner, and having a history of psychiatric illness including a diagnosis of posttraumatic stress disorder, were related to worse scores on the PDI and PAIRS questionnaires, with multiple surgeries being significantly related to worse scores on the OLBPDQ. At 12 months, descriptive analysis of PDI and OLBPDQ responses suggested that patients continued to maintain their improvements compared to the pre-programme assessment. However on the PAIRS a small deterioration was noted, indicating that pain and disability beliefs were reverting to pre programme levels. Discussion in this thesis focuses on an exploration of the factors impacting on the results including the influence of gender, psychiatric history, trauma and number of years in pain. The difficulties inherent in using outcome measures to measure small clinical gains are also explored. Limitations of this study include the small sample size and the reduced response rate to outcome measures. Nonetheless, a replication of the study over a longer period with greater attention to obtaining follow-up data would be worthwhile.