Psychologically-orientated Rehabilitation Programmes and their Outcomes
Dr Chris Wells, England, UK
Back pain is the most common symptom seen in Pain Clinics, and back pain and sciatica have affected man throughout history. The Edwin Smith papyrus, circa 1500 BC, includes a case of back strain. There is no evidence that back pain has changed over the years, but the way in which we treat it now, as compared with three and a half thousand years ago, is very different.
Sadly, this plethora of treatments has not produced a reduction in the disability and distress caused by back pain. Indeed, this disability is increasing at a terrifying rate. Figures from the UK indicate that with the present growth in disability, the whole of the population will be off sick by the year 2016.
The symptom of back pain is a common link between a number of serious spinal diseases. However, before the last century most back pain was dismissed as fleeting pain or rheumatics. Few people became chronically disabled by simple backache. Throughout this century, doctors have "medicalised" the condition, assumed diagnostic insight, carried out procedures on the basis of little evidence and claimed results on the basis of even less evidence.
It is estimated that in 85 per cent of people with back pain, the cause is unknown. That is not to say there is no cause, but we don't know what it is. Why should we treat these patients with procedures, some of them invasive and some of them carrying complications? Of course all the clinicians here would agree that assessment is even more important than the treatment itself.
Over the last thirty years, the clear importance of a bio-psycho-social model in assessing pain, and in particular back pain, has been recognised. Attitudes and beliefs require cognitive therapy. Psychological distress requires appropriate management. Illness behaviour may respond to behavioural techniques. This social environment needs to be manipulated in a way that is positive for the patient and not to his detriment.
Pain Management Programmes were developed in the US by pioneers such as Fordyce and Sternbach in the 1960s. They usually started as being intensive behavioural modification programmes run by Psychologists. They gradually evolved to become multi-disciplinary including clinicians, physiotherapists, occupational therapists and nurses, as well as the psychology team. Other adjunct personnel can also be appropriate.
The first Pain Management Programme in the UK was commenced by Dr Eric Ghadiali and Dr Chris Wells in 1983. Unlike the majority of American programmes, it was run as an out-patient programme and still is. It is interesting to note that, because of cost, many American programmes have changed to this modality. Cost efficacy studies reveal that out-patient programmes can help a significant number of sufferers at low cost. Others might benefit from an in-patient programme, which is, however, much more expensive.
The Pain Management Programme at Walton Hospital in Liverpool runs as a four week course, with patients attending for four days a week (Tuesday to Friday) for that full period. It is a staggered course, so that two patients in each group of eight start anew each week and by the end of the course the two most "senior" patients help the others. They are often excellent role models to support the tyro.
Only patients who have completed other treatments should be selected. That is, there is no point in a patient attending who is still waiting for surgery or injections, which have been proffered as a cure. Patients must not only have pain of a moderate to severe nature but also have significant distress and disability as a result of this. They need to accept the rationale behind graded exercise and psychological intervention, in combination with their rehabilitation.
Structure of the Course
Every course is different. The most essential part of the course is the group. Group therapy is effective in many societal problems, including alcoholism, weight and so on. Within the range of therapists, there need to be physicians specialising in the treatment of pain, clinical psychologists and physiotherapists. Nurses and occupational therapists are also important. Other therapists vary according to local supply and need.
The Walton course has a full range of activity for 8 hours a day, four days per week. Patients are then given tasks and set goals to accomplish at home over a 3-day period. Every day has 2 activity periods. One of these is a formal physiotherapy session; the other ranges from swimming to T'ai Chi, dance and so on. Each patient is assigned an individual counsellor, but all activities are performed in groups. Every day contains a relaxation session, a session on psychological factors, including self-management, and each week has at least one lecture from a doctor.
This will be presented. Average visual analogue scales fall, but only slightly. Within this there is a range of patients who get no improvement in pain whatsoever, and those who get a significant and worthwhile drop. However, the programme scores more highly in reduction of disability and distress. Patients are assessed at the beginning and end of the course, at 3 months, 6 months, 1 year and 2 years. It has been found that there is no long-term deterioration after 6 months and consequently assessment is finished at this time.
Pain Management Programmes are a useful part of pain therapy. Good selection is essential. Patients must have had all aspects of their physical and nociceptive problems addressed as thoroughly as possible. Medication needs to be optimal. With good patient selection and informed staff many chronic sufferers, with little that can be offered in the way of treatment, can get useful benefit.
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