By Thomas G. Ciccone
Interview with Lawrence Kei, MD
At the CHANGEpain Clinic (CpC), a community based chronic pain center based in Vancouver, Canada, clinicians have taken a layered approach to myofascial pain care, using a first-line approach of self-management therapies. The treatment approach focuses on helping patients improve their diet, stress levels, and sleep before employing more expensive interventions.
According to Lawrence Kei, MD, in the Department of Physical Medicine and Rehabilitation at the University of British Columbia, the methodology may be focused on cost-effectiveness but also could be achieving significant clinical improvements for some patients.
“Obviously in Canada we have a public-funded system, so we can’t go straight to the injections and everything,” Dr. Kei told PPM. During Dr. Kei’s presentation, he explained that many community-based pain clinics may benefit from this treatment approach, although up to this point, there had been a paucity of studies looking at the efficacy of this form of treatment for myofascial pain syndrome.
In a retrospective observational study, Dr. Kei and his colleagues collected data on thousands of patients who had been treated at the CpC from May 1, 2013 to December 31, 2015, pulling together data on Brief Pain Inventory (BPI) and Pain Numeric Rating Scale (NRS) scores taken at the initial visit and once during a follow-up visit.1 The study also used data from other questionnaire scales, including:
- Patient Health Questionnaire-9 (PHQ9) to record depressive symptoms
- Patient Self-Efficacy Questionnaire (PSEQ) to record self-management and confidence with chronic pain
- Patient Related Self-Statements (PRSS) to record details on catastrophizing or active coping behaviors
- Tampa Scale of Kinesiophobia (TSK) to record excessive fear of physical movement
Overall, more patients appeared to benefit from the layered treatment approach as 47.82% patients reported improved pain symptoms while 14.63% reported worsened pain. In order to understand why some patients benefitted and others did not, the researchers decided to a do a full review of the patients’ chart information.1
Dr. Kei and his colleagues examined patients from both ends of the spectrum—30 patients whose conditions improved the most and 30 patients whose conditions deteriorated the most—to determine a possible rationale to distinguish between patients who responded well to the treatment and those who did not improve.
The researchers noticed an interesting pattern: at the initial visit, patients with the worst BPI and depressive symptoms ended up showing the greatest improvement following treatment. Conversely, patients who had improved the least had started off with more moderate pain and BPI scores but then deteriorated significantly over time.
Contrasts were stark between the “improved” and “deteriorated” patient groups. For patients who improved the most, PHQ9 depression scores decreased from mean scores of 16.13 (SD 6.30) to 9.16 (SD 6.78). For patients who deteriorated the most, PHQ-9 depression scores increased from 11.86 (SD 6.70) to 14.41 (SD 6.84).1
Questions About Multilayered Myofascial Pain Care
The trend might suggest that patients with the most serious comorbid depression and weight issues may benefit most from a community-based myofascial pain treatment center that uses a multilayered approach that incorporates aspects of care, such as a group nutrition program, which focuses on educating patients about dietary choices to promote an anti-inflammatory, healthier gut.
“While many of these added treatments are nonpharmacologic, lifestyle interventions, the clinical benefits can be significant,” Dr. Kei said. “It’s interesting because this particular clinic focuses more on myofascial techniques, first,” which includes trigger point injections, myofascial pain removal, and group physical therapy sessions. The addition of self-management training and movement coaching may have improved select patients’ lifestyle and functional status.
“If these techniques were not successful, other interventions would be employed, such as ultrasound-guided injections, caudal epidural injections, and medial branch blocks,” Dr. Kei explained. But since these techniques are not part of the core program, fewer patients received them.
Patients with average, more moderate scores deteriorated significantly by the time they had their follow-up evaluation.
There was no clear trend based on their specific diagnosis. Patients who deteriorated the most reported a range of ailments, including various mechanical pain disorders, systematic widespread disorders, osteoarthritis, headache, as well as various psychiatric disorders, such as depression and anxiety (Figure 1).
However, patients who deteriorated the most did show a significantly longer time to their follow-up evaluation. While the mean days to follow-up for patients who improved the most was 86.2 days (SD 68.4), the average for patients who deteriorated the most was 160.8 days (SD 158), basically double the amount of time.
Still, there is no clear explanation for the greater deterioration among patients taking twice as long to return to the clinic for a follow-up visit. Whether this longer time interval had a direct effect on the outcome of the interventions they received remains unknown, according to Dr. Kei.
Dr. Kei and his colleagues intend to perform a full statistical analysis in the future. The goal would be to determine if the treatments for depression differed significantly between the “improved the most” versus the “deteriorated the most” groups, which may help to explain the contrasting patient outcomes.
“It is possible that the difference in PHQ9 scores were more a result of improvement in pain than treatment of depression,” the authors wrote. This could be possible, considering self-efficacy scores (PSEQ) did improve for the “improved the most” patients, but did not change at all for the “deteriorated the most” patient group.
Dr. Kei has no conflicts with regard to this study.
- Kei L, Lau B, Berry C, et al.Characteristics of a smaple of chronic pain patients who either made significant improvements or deteriorated during treatment of a community based outpatients chronic pain clinic: A retrospective observational study. Presented at: PAINWeek, September 6-10, 2016; Las Vegas, Nevada.