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Service Line: Rapid Response Service

Version: 1.0

Publication Date: August 4, 2017

Report Length: 19 Pages

CADTH RAPID RESPONSE REPORT: SUMMARY WITH CRITICAL APPRAISAL

Occupational Therapy for Chronic Pain Management Using the Biopsychosocial Approach: A Review of the Clinical and Cost-Effectiveness and Guidelines

SUMMARY WITH CRITICAL APPRAISAL Occupational Therapy for Chronic Pain Management Using the Biopsychosocial Approach 2

Authors: Chuong Ho, Charlene Argez

Cite As: Occupational therapy for chronic pain management using the biopsychosocial approach: a review of the clinical and cost-effectiveness and guidelines.

Ottawa: CADTH; 2017 Jul. (CADTH rapid response report: summary with critical appraisal).

ISSN: 1922-8147 (online)

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Context and Policy Issues

The International Association for the Study of Pain (IASP) defines pain as an unpleasant

sensory and emotional experience associated with actual or potential tissue damage and

chronic pain as pain persisting beyond the normal expected time of healing,1 which is

typically considered pain that lasts for three to six months or more.2 It has recently been

reported that one in five Canadians struggle with chronic pain,3-5

with chronic low back pain

being the most common chronic pain condition.6,7

The annual costs of treating chronic pain

in the United States were greater than the costs of treating heart disease, cancer, and

diabetes combined, with up to $635 billion annually attributed to medical costs and lost

productivity in the United States in 2010 dollars.8

Treatment options for chronic pain can be pharmacologic (i.e., pain medication which can

include opioids or non-opioid analgesics), and/or non-pharmacologic, including physical

treatment, surgery, and occupational or multimodal therapy using the biopsychosocial

approach which addresses the biological, psychological and social aspects of the

condition.9-20

Because of the harmful, dose-dependent deleterious effects of opioid

treatment, including addiction, increased risk of injuries, respiratory depression,

hyperalgesia, and death,21-23

there is a need for non-opioid, multi-disciplinary approaches

such as biopsychosocial therapy for diverse chronic pains, from low back pain, to

headache, musculoskeletal pain, and cancer-related pain.24-35

This Rapid Response report aims to review the clinical and cost-effectiveness of

occupational therapy using a biopsychosocial approach to manage chronic pain compared

to opioids, no treatment, placebo, or waiting list. Evidence-based guidelines regarding

occupational therapy using a biopsychosocial approach to manage chronic pain will also be

examined.

Research Questions

1. What is the clinical effectiveness of occupational therapy using a biopsychosocial

approach to manage chronic pain?

2. What is the cost-effectiveness of occupational therapy using a biopsychosocial


3. What are the evidence-based guidelines regarding occupational therapy using a

biopsychosocial approach to manage chronic pain?

Key Findings

The findings of a systematic review of patients with chronic low back pain show that

multidisciplinary biopsychosocial rehabilitation interventions seem to be more effective than

usual care (which generally involved pain medication and physical treatment) or physical

treatments in decreasing pain and disability; multidisciplinary rehabilitation seems to be

more effective than physical treatment in work absenteeism but not more effective than

usual care. Based on evidence from two prospective non-randomized studies in patients

with chronic pain and chronic musculoskeletal pain, a multimodal psychosocial approach

may have a better effect on pain, disability, depression and different domains of life

satisfaction compared with usual care or no treatment. There was no evidence found on


the cost effectiveness of, and the evidence-based guidelines for, occupational therapy

using a biopsychosocial approach to manage chronic pain.

Methods

A limited literature search was conducted on key resources including PubMed, The

Cochrane Library, University of York Centre for Reviews and Dissemination (CRD)

databases, Canadian and major international health technology agencies, as well as a

focused Internet search. No filters were applied to limit the retrieval by study type. Where

possible, retrieval was limited to the human population. The search was also limited to

English language documents published between January 1, 2012 and July 10, 2017. Rapid

Response reports are organized so that the evidence for each research question is

presented separately.

Selection Criteria and Methods

One reviewer screened citations and selected studies. In the first level of screening, titles

and abstracts were reviewed and potentially relevant articles were retrieved and assessed

for inclusion. The final selection of full-text articles was based on the inclusion criteria

presented in Table 1.

Table 1: Selection Criteria

Population Any patient with chronic pain (pediatric and adult)

Intervention Occupational therapy using the biopsychosocial approach

Comparator Q1 and Q2: Opioids, no treatment/placebo/wait list

Q3: No comparator required

Outcomes Q1: Clinical benefits and harms

Q2: Cost-effectiveness outcomes

Q3: Evidence-based guidelines and recommendations

Study Designs Heath technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-

randomized studies, economic evaluations, evidence-based guidelines

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1, they

were duplicate publications were already reported in the included SRs, or were published

prior to 2012. Guidelines with unclear methodology were also excluded.

Critical Appraisal of Individual Studies

The included systematic review and clinical studies were assessed using the AMSTAR36

and Downs and Black37

checklists, respectively. Summary scores were not calculated for

the included studies; rather, a review of the strengths and limitations of each included study

were described narratively.


Summary of Evidence

Quantity of Research Available

A total of 423 citations were identified in the literature search. Following screening of titles

and abstracts, 411 citations were excluded and 12 potentially relevant reports from the

electronic search were retrieved for full-text review. Three potentially relevant publications

were retrieved from the grey literature search. Of these potentially relevant articles, 12

publications were excluded for various reasons, while three publications met the inclusion

criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the

study selection. References of potential interest (studies without a comparator group) are

provided in Appendix 5.

Summary of Study Characteristics

The included review38

is a systematic review and meta-analysis of randomized controlled

trials on patients with chronic low back pain undergoing multimodal biopsychosocial

treatment. It included 41 trials with 6858 participants with a mean age of 40 to 45 years (16

trials vs. usual care; 19 trials vs. physical treatment; 2 trials vs. surgery; 4 trials vs. waiting

list). Usual care was not clearly defined; however, the review indicated that it implies pain

medication and physical treatment. Outcomes reported were pain intensity (using a 10-

point Visual Analogue Scale), disability level (using the 24-point Roland-Morris Index), and

work absenteeism. The review was conducted in Australia, the Netherlands, and Canada.

The included clinical trials were prospective longitudinal studies.39,40

One study39

included

296 patients with chronic musculoskeletal pain with the intervention as a multimodal

rehabilitation program (using a biopsychosocial approach) and the comparator as usual

unimodal rehabilitation program. Outcomes reported were pain intensity (using a 100-mm

horizontal Visual Analogue Scale, with 0 representing no pain and 100 representing

worst imaginable pain), disability level (using the 100-point Disability Rating Index, with 0

representing manage without difficulty and 100 indicating cannot manage at all),

depression (using the 14 item, 21-point Hospital Anxiety and Depression Scale, with the

categories of normal, mild, and moderate/severe), and life satisfaction (using the 11-

domain LiSat questionnaire, with higher scores indicating higher levels of life satisfaction).

Assessments were made after one-year follow-up. The study was conducted in Sweden.

One study40

included 527 patients with chronic pain with intervention as physiotherapy, or

psycho-education, or physiotherapy combined with psycho-education, or self-hypnosis and

self-care learning, and comparator as waiting list/no intervention. Outcomes reported were

pain intensity (using a 10-point Visual Analogue Scale, with increasing scores indicating

more intense pain), disability level (using the 100-point Disability Rating Index), depression

(using 21-point Hospital Anxiety and Depression Scale), and general health (using the 100-

point Short Form-36 measure of eight dimensions of health, including a Physical

Component Summary and Mental Component Summary; higher scores indicate better

health). Mean duration between pre- and post-intervention health assessment was 9 3

months. The study was conducted in Belgium.

Characteristics of the included studies are detailed in Appendix 2.

Summary of Critical Appraisal

The included systematic review38

provided an a priori design and performed a

comprehensive literature search. Procedures for the independent duplicate selection and

data extraction of the study were in place, a list of included studies and characteristics were

provided, and quality assessment of the included studies was used in formulating


conclusions. Some degrees of clinical heterogeneity across trials such as variation in

biopsychosocial treatments and usual care, as well as differences between included trials

in terms of quality (ranging from low to moderate quality) lead to possible heterogeneity

issues when data were pooled. The review assessed publication bias and did not include a

list of excluded studies.

The included clinical studies39,40

were observational in nature with no randomization

leading to potential selection bias. The hypotheses, method of selection from source

population and representation of the study population, main outcomes, interventions,

patient characteristics, and main findings were clearly described, and estimates of random

variability and actual probability values were provided. It was unclear whether the study

had sufficient power to detect a clinically important effect, as no power calculation was

reported.

Details of the critical appraisal of the included studies are presented in Appendix 3.

Summary of Findings

The main findings of the included studies are presented in Appendix 4.

What is the clinical effectiveness of occupational therapy using a biopsychosocial


The included systematic review38

on patients with chronic low back pain found that after

one year of treatment, multidisciplinary biopsychosocial therapy was more effective in

reducing pain intensity and disability level compared with usual care, but the two

approaches had a similar effect on work absenteeism. Compared with physical treatment,

biopsychosocial therapy reduced disability and work absenteeism, but the comparison did

not reach statistical significance for pain. Compared with surgery, a biopsychosocial

therapy approach had a similar effect on pain, disability and work absenteeism, but more

adverse events (details not provided) occurred with surgery. Compared with waiting list, a

biopsychosocial therapy approach reduced pain and disability; there were no data on work

absenteeism for this comparison. The authors concluded that multidisciplinary

biopsychosocial rehabilitation interventions were more effective than usual care (moderate

quality evidence) and physical treatments (low quality evidence) in decreasing pain and

disability in people with chronic low back pain. Multidisciplinary rehabilitation seems to be

more effective than physical treatment in work outcomes but not more effective than usual

care.

One included clinical trial39

found that, compared to baseline after one-year follow-up, the

biopsychosocial approach significantly reduced current pain intensity as well as pain

intensity of last week, disability level, depression, and life satisfaction in all three measured

outcomes (leisure, somatic health and psychological health) in patients with chronic

musculoskeletal pain. Usual rehabilitation care statistically improved measurements of pain

last week and somatic health from measurements of those outcomes at baseline;

comparison to baseline was not conclusive for the other outcomes. The authors concluded

that multimodal rehabilitation may have long-term positive effects on pain, disability,

depression and domains of life satisfaction.

The second included trial40

found that, in patients with chronic pain, compared to baseline

after a mean of nine months follow-up, there was a statistically significant decrease in

anxiety with physiotherapy or psycho-education treatment and with self-hypnosis and self-

care treatment, a significant decrease in depression in self-hypnosis and self-care

treatment, a significant improvement in the mental component of the Short-Form-36


questionnaire in both psycho-education and self-hypnosis and self-care treatments, a

significant decrease in disability with both physiotherapy or psycho-education treatment

and self-hypnosis and self-care treatment, and a significant diminution of pain intensity in

self-hypnosis and self-care treatment. There was no statistically significant difference

compared to baseline values in all measured outcomes in the no-treatment group. The

authors concluded that the study has shown the relevance of biopsychosocial approaches,

in particular the self-hypnosis/self-care treatment, in the improvement of pain and

psychological factors in chronic pain patients.

A list of trials of potential interest on the clinical effectiveness of the biopsychosocial

approach which do not have a comparator group is listed in Appendix 5.

What is the cost-effectiveness of occupational therapy using a biopsychosocial approach to

manage chronic pain?

There was no evidence found regarding the cost-effectiveness of occupational therapy using a biopsychosocial approach to manage chronic pain.

What are the evidence-based guidelines regarding occupational therapy using a biopsychosocial approach to manage chronic pain?

There was no evidence found in evidence-based guidelines regarding occupational therapy

using a biopsychosocial approach to manage chronic pain

Limitations

Evidence from the included systematic review and meta-analysis should be interpreted with

caution due to clinical heterogeneity across trials which may have affected the pooled

estimates when data were pooled. Blinding in the included trials was not possible for

patients, clinicians and assessors due to the nature of the interventions which may have

introduced ascertainment bias.

Conclusions and Implications for Decision or Policy Making

In patients with chronic low back pain, multidisciplinary biopsychosocial rehabilitation

interventions seem to be more effective than usual care and physical treatments in

decreasing pain and disability; multidisciplinary rehabilitation seems to be more effective

than physical treatment at reducing work absenteeism but not more effective than usual

care. In patients with chronic pain and chronic musculoskeletal pain, multimodal

psychosocial therapy may have a better effect on pain, disability, depression and different

domains of life satisfaction compared with usual care or no treatment. There was no

evidence found on the cost effectiveness of, and the evidence-based guidelines for,

occupational therapy using a biopsychosocial approach to manage chronic pain.

Openness to patients psychosocial concerns is important as reflected by patients reporting

lowest satisfaction with the attention of their practitioners to the existential domain

(meaning and purpose of life) and social domain; this dissatisfaction in turn may affect their

health-related behaviour, depression, and treatment success.41

However, promoting non-

pharmacological multimodal treatment approaches may not be easy once opioid therapy is

started, and patients may be skeptical about the efficacy of this approach.42

Stakeholder

dialogues have been conducted in Canada to summarize the evidence and elicit policy

makers and stakeholders knowledge and views to improve chronic pain management.

Development of a national network and a national pain strategy are important initiatives to

improve chronic pain management in Canada.43

A 2014 cost study of chronic pain in

adolescents in the US found that the primary driver of costs was direct medical costs


followed by productivity losses,44

which emphasizes the need for effective treatments for

chronic pain. Legislative efforts to reform workers compensation law using the

biopsychosocial model seemed to provide good care while controlling costs in the

treatment of injured workers.45

The clinical benefits of the intervention should be weighed

against the monetary costs and time commitments associated with multidisciplinary

rehabilitation programmes.

Randomized controlled trials to compare biopsychosocial approach to opioids are needed

to confirm the comparative effectiveness of the multimodal approach to opioid analgesics in

the treatment of patients with chronic pain. Cost-effectiveness studies on the use of

biopsychological therapy are needed to formulate guidelines on the use of the approach.


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Appendix 1: Selection of Included Studies

411 citations excluded

12 potentially relevant articles retrieved for scrutiny (full text, if available)

3 potentially relevant reports retrieved from other sources (grey

literature, hand search)

15 potentially relevant reports

12 reports excluded: - irrelevant intervention (3) - no comparator (3) - irrelevant outcome (1) - reviews (5)

3 reports included in review

423 citations identified from electronic literature search and screened


Appendix 2: Characteristics of Included Publications Table A1: Characteristics of Included Systematic Review

First Author, Year, Country

Objectives Literature Search

Strategy

Inclusion Criteria Exclusion Criteria Number of studies included

Main Outcomes

Kamper,38

2015, Canada, Australia, Netherlands

Systematic review and meta-analysis of randomised controlled trials To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain (p 1)

Trials (RCTs) published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by health care professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention (p 1)

Studies not fulfilling the inclusion criteria

Total of 41 trials on multimodal biopsychosocial approach with 6858 participants 16 trials vs. usual care (varied across studies but usually involved pain medication and physical treatment); 19 trials vs. physical treatment (heat and electrotherapeutic modalities; aerobic, stretching, and strengthening exercises); 2 trials vs. surgery; 4 trials vs. waiting list (no treatment). Mean age across studies: 40 - 45 years Mean duration of symptoms > 1 year Outcomes measured: Pain (Visual Analogue Scale) Disability (Roland-Morris Index) Work absenteeism


Table A2: Characteristics of Included Clinical Studies

First Author, Year, Country

Study Design Study Objectives

Interventions/Comparators

Patients Main Outcomes

Merrick,39

2012, Sweden

Prospective longitudinal study To determine outcomes for 2 rehabilitation strategies for patients with chronic pain: a 2-day interdisciplinary team assessment followed by either: (i) a 4-week outpatient multimodal rehabilitation programme, or (ii) a subsequent rehabilitation plan (p 764)

Multimodal rehabilitation program (biopsychosocial approach) Usual rehabilitation program (details not provided)

296 patients with chronic musculoskeletal pain (76 multimodal; 220 usual rehabilitation plan) Mean age: 39.5 years

Pain (Visual Analogue Scale) Disability (Disability Rating Index) Depression (Hospital Anxiety and Depression Scale) Life satisfaction (LiSat-11) Assessment after 1-year follow -up

Vanhaudenhuyse40

2015, Belgium

Prospective longitudinal study The aim of this study was to explore the effectiveness of pain interventions in reducing disability associated with chronic pain (p 1441)

Physiotherapy Psycho-education Physiotherapy combined with psycho-education Self-hypnosis/self-care learning Control group (waiting list, no intervention)

527 patients with chronic pain (61 physiotherapy; 50 psycho-education; 169 physiotherapy combined with psycho-education; 158 self-hypnosis/self-care learning; 89 control) Mean age: 54 11 years Mean duration of pain: 116 118 months

Pain (Visual Analogue Scale, Pain Disability Index) Depression (Hospital Anxiety and Depression Scale) General health (Short Form-36, including physical and mental component summary scores) Mean duration between pre- and post-health assessment was 9 3 months.


Appendix 3: Critical Appraisal of Included Publications

Table A3: Strengths and Limitations of Clinical Systematic Reviews using AMSTAR36

Strengths Limitations

Kamper38

a priori design provided

independent studies selection and data extraction procedure in place

comprehensive literature search performed

list of included studies, studies characteristics provided

quality assessment of included studies provided and used in formulating conclusions

assessment of publication bias performed

conflict of interest stated

list of excluded studies not provided

Table A4: Strengths and Limitations of Clinical Studies using Downs and Black37

Strengths Limitations

Merrick39

hypothesis clearly described

method of selection from source population and representation described

loss to follow-up reported

main outcomes, interventions, patient characteristics, and main findings clearly described

estimates of random variability and actual probability values provided

observational study; patients not randomized

unclear whether study had sufficient power to detect a clinically important effect

Vanhaudenhuyse40

hypothesis clearly described

method of selection from source population and representation described

loss to follow-up reported

main outcomes, interventions, patient characteristics, and main findings clearly described

estimates of random variability and actual probability values provided

observational study; patients not randomized

unclear whether study had sufficient power to detect a clinically important effect


Appendix 4: Main Study Findings and Authors Conclusions

Table A5: Summary of Findings of Included Clinical Studies

Main Study Findings Authors Conclusion

Kamper38

Multidisciplinary biopsychosocial rehabilitation interventions compared to usual care Pain intensity (data from 16 trials of moderate quality evidence) SMD 0.21, 95% CI 0.04 to 0.37 Disability (data from 16 trials of moderate quality evidence) SMD 0.23, 95% CI 0.06 to 0.40 Work absenteeism (data from 7 trials of moderate quality evidence) Odds ratio1.04, 95% CI 0.73 to 1.47 Statistical heterogeneity was low across trials Multidisciplinary biopsychosocial rehabilitation interventions compared to physical treatment Pain intensity(data from 19 trials of low quality evidence) SMD 0.51,95% CI -0.01 to 1.04 Disability (data from 19 trials of low quality evidence) SMD 0.68, 95% CI 0.16 to 1.19 Significant statistical heterogeneity across trials was present for pain and disability outcomes Work absenteeism (data from 8 trials of low quality evidence) Odds ratio 1.87, 95% CI 1.39 to 2.53 Multidisciplinary biopsychosocial rehabilitation interventions compared to surgery Pain intensity (data from 2 trials of low quality evidence) SMD 0.25, 95% CI -0.04 to 0.53 Disability (data from 2 trials of low quality evidence) SMD 0.25, 95% CI -0.08 to 0.57 Work absenteeism (data from 2 trials of low quality evidence) Odds ratio 0.67, 95% CI 0.31 to 1.45 Adverse events (data from 2 trials of low quality evidence) Odds ratio 28.25, 95% CI 3.77 to 211.93 Multidisciplinary biopsychosocial rehabilitation interventions compared to waiting list Pain intensity (data from 3 trials of low quality evidence) SMD 0.73, 95% CI 0.24 to 1.22

Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care (p 1)




Disability (data from 3 trials of low quality evidence) SMD 0.49, 95% CI 0.22 to 0.76

Merrick39

For the MMR group Pain intensity (at 1-year follow-up, compared to baseline) From 59 (mean; SD 22) to 46 (SD 27) for VAS current pain (p = 0.002) From 64 (mean; SD 22) to 47 (SD 27) for VAS mean pain last week (p < 0.001) Disability (at 1-year follow-up, compared to baseline) Improved significantly Light work (P< 0.001), Heavy work (P< 0.002) Depression (at 1-year follow-up, compared to baseline) Improved significantly (P < 0.007) Life satisfaction (at 1-year follow-up, compared to baseline)Improved significantly Leisure (P = 0.001) Somatic health (P < 0.001) Psychological health (P< 0.001)

For the usual rehabilitation group

Pain intensity (at 1-year follow-up, compared to baseline) From 67 (mean; SD 19) to 60 (SD 24)for VAS mean pain last week (P< 0.001) Life satisfaction (at 1-year follow-up, compared to baseline) Somatic health improved significantly (P = 0.013) No statistically significant improvements found for other variables

This study indicates that multimodal rehabilitation may have long-term positive effects on pain, disability, depression and domains of life satisfaction (p 764)

Vanhaudenhuyse40

Changes in the pre-treatment to post-treatment (measured by HADS, SF-36, PDI and VAS scores; assessment at mean 9 3 months) Significant decrease in anxiety in physiotherapy/psycho-education treatment (P = 0.04) and in self-hypnosis/self-care treatment (P




(P


Appendix 5: Trials of potential interest on the biopsychosocial approach with no comparator group Volker G, van Vree F, Wolterbeek R, van Gestel M, Smeets R, Kke A, et al. Long-term

outcomes of multidisciplinary rehabilitation for chronic musculoskeletal pain.

Musculoskelatal Care. 2017;15(1):59-68.

Hallstam A, Lfgren M, Svensn C, Stalnacke BM, Patients with chronic pain: one-year

follow-up of a multimodal rehabilitation programme at a pain clinic. Scand J Pain.

2016;10:36-42.

Quinlan J, Hughes R, Laird D. Independent validation of the Pain Management Plan in a

multi-disciplinary pain team setting. Br J Pain. 2016;10(4):168-176.

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