Chronic pain can be potentially debilitating, reducing a patient’s functional status and quality of life. Available treatments for this condition include either multidisciplinary interventions or single-discipline approaches with varying levels of efficacy. Various studies have evaluated the effectiveness of opioid use, alternative medicine, cognitive-behavioral rehabilitation, and other therapies for pain management. This paper reviews scholarly evidence for the efficacy of the existing modes of treatment for chronic pain.
Article Summary
A literature search was conducted to identify three relevant articles for this analysis. Jacobs et al. (2016) assessed the short-term and long-term efficacy of advanced soft tissue release (ASTR) in treating injury-related neck pain. The biopsychosocial treatment is a holistic approach to treating sprain- or strain-type injuries primarily through stretching soft tissues, behavior change, and physical activity. Through a retrospective cohort study, patients with chronic neck pain and receiving therapy at a medical facility were included in the sample.
Patient charts were used to collect demographic information on the subjects’ age and sex. Additionally, past treatments, symptom type and onset, and visual analog scale (VAS) rating before and after ASTR intervention were obtained from these tools (Jacobs et al., 2016). The VAS pain scores of the patients were taken after a 12-month follow-up period.
The mean pre-treatment VAS rating was 7.51, which dropped significantly to 0.31 at the last ASTR session (Jacobs et al., 2016). At the end of the follow-up period, an average VAS of 0.49 was reported. Additionally, 83%, 84%, and 87% of the patients had no neck pain after the first ASTR, at last treatment, and one-year post-discharge, respectively. The researchers concluded that ASTR is effective in relieving neck pain both in the short and long run.
Kamper et al. (2015) evaluated the long-term effect of holistic biopsychosocial therapy for chronic low back pain (CLBP). This systematic review analyzed randomized controlled trials (RCTs) published in multiple databases, including Medline and CINAHL. Selected studies were RCTs examining multidisciplinary rehabilitation that included physical, mental, and social components and performed by interprofessional teams (Kamper et al., 2015). Forty-one trials were chosen for the analysis.
The combined participants were 6858 and had an average pain duration of over 12 months. Moderate-quality evidence for the efficacy of biopsychosocial therapy in reducing pain was found in 16 RCTs over standard care (p≤0.04-0.37). The other studies did not provide sufficient proof that multidisciplinary rehabilitation is better than physical intervention or surgery for treating CLBP. Therefore, biopsychosocial treatments have higher efficacy than standard care in pain management but high-quality evidence is lacking.
In a related article, Rauck et al. (2015) assessed the efficacy of buccal buprenorphine (BBUP) film delivered through the BioErodible MucoAdhesive technology in CLBP management. The study used a multi-center, double-blind randomized design. A sample of 749 opioid-naïve patients received 150-450 microgram dosage of BBUP intravenously after a 12-hour interval (Rauck et al., 2015).
High tolerability was recorded in this group, which was subsequently randomly assigned to BBUP (229 subjects) and placebo (232 participants). The results indicated a pain decrease from severe (7.15) to mild levels (2.81) at week 12 after the initial BBUP titration. Further, pain relief was significantly higher in the BBUP group than in the placebo arm (1.59 vs. 0.94). These findings show that BBUP is effective and well tolerated by opioid-naïve patients with CLBP.
Synthesis
Interventions for treating chronic pain range from single-discipline treatment forms to multidisciplinary methods. Research evidence shows that some therapies are effective compared to others in long-term pain relief and have few adverse outcomes. Titration of low-dose opioids, such as BBUP, seems to decrease chronic pain within a shorter period – 12 weeks (Rauck et al., 2015). BBUP’s clinical efficacy comes from its prolonged analgesic activity and reduced risk of dependence when administered intravenously.
However, its long-term effect is low compared to other interventions. The biopsychosocial model can produce prolonged CLBP relief for up to one year (Kamper et al., 2015). A typical multidisciplinary rehabilitation program includes physical therapy (heat treatment and acupuncture), psychological aspect (CBT), and a social component delivered by interprofessional teams.
Moderate-quality evidence has shown this holistic model to be more effective for pain relief than usual care or surgery (Kamper et al., 2015). In general, treatments following the biopsychosocial framework appear to produce long-term CLBP reduction and better functioning compared to single modality interventions, such as opioid use.
ASTR, a specialty therapeutic approach that uses the multidisciplinary model, is effective for neck pain relief. It entails working on different aspects meant to treat musculoskeletal and neuromuscular tissue dysfunctions (Jacobs et al., 2016). The intervention holistically tackles scarifications, muscle cramps, fibrosis, behavior, and diet using various ASTR tools, patient training, and exercise. Therefore, ASTR yields quick, long-term relief for neck pain because it addresses diverse factors related to the injury. Consistent with the biopsychosocial model, ASTR tackles social aspects (habits), physical variables (dysfunctional tissues or scars), and psychological (mindset) causes of the pain.
Evaluation
The articles reviewed have some strengths and weaknesses. Jacobs et al. (2016) can be evaluated based on the representativeness of the sample, setting, and procedures. The authors admit that random sampling was not done, affecting the 95% confidence intervals computed for the variables. The largely uniform geographic, demographic, social, and economic conditions may have limited the representativeness of the sample, as the study participants were only drawn from patients attending a physical therapy clinic.
However, the sample size (n=105) seems adequate to make a general inference about ASTR’s efficacy in neck pain relief. The unique characteristics of this setting that offers neck injury care may be generalized to other facilities that treat patients with soft tissue problems or orthopedic surgery environments. Both the ASTR protocol and VAS tools used involve procedures that can be replicated in other settings.
Kamper et al. (2015) reviewed RCTs with a combined sample size of 6,858, which can be considered adequate for inferring about the intervention. This meta-analysis provides the strongest evidence (level 1) for the effectiveness of multidisciplinary rehabilitation interventions in treating chronic low back pain.
Thus, it can guide clinical practice in this area. However, the specific domains and configurations of interprofessional teams that would yield optimal results were not identified. Further, only moderate-quality evidence for the efficacy of biopsychosocial treatments over usual care was found.
The study by Rauck et al. (2015) was conducted in 50 different sites and involved 749 randomized patients, which enhanced the extent to which it can be generalized to other population conditions. The randomization process eliminated selection bias, while the double blind, placebo-controlled approach limited to 12 weeks reduced maturation effects that could threaten internal validity.
However, the study sample was restricted to opioid-naïve adults with CLBP. Thus, the findings may not be generalized to other patient populations. Additionally, the study was conducted for 12 weeks, thus, the long-term efficacy of BBUP may not be inferred. The efficacy and tolerability of BBUP were measured against a placebo, not versus other opioids.
Conclusion
Chronic pain affects physical functioning and emotional wellbeing. Multiple treatments exist for reducing pain intensity, ranging from single-discipline interventions to holistic approaches. From the articles reviewed, multimodal approaches that use the biopsychosocial model produce positive long-term outcomes compared to opioid treatment alone. Therefore, individuals with chronic pain can benefit from multidisciplinary care programs that combine multiple treatment options.
References
Jacobs, J., Wilson, J., & Ireland, K. (2016). Advanced soft tissue release® (ASTRA®) long-and short-term treatment results for patients with neck pain. MedCrave Online Journal of Orthopedics & Rheumatology, 5(4), 1-5.
Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder,M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. The British Medical Journal, 350(h444), 1-11.
Rauck, R. L., Potts, J., Xiang, Q., Tzanis, E., & Finn, A. (2015). Efficacy and tolerability of buccal buprenorphine in opioid-naive patients with moderate to severe chronic low back pain. Postgraduate Medicine, 128(1), 1–11.