Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Elena Tseli, Katja Boersma, Britt-Marie Stålnacke, Paul Enthoven, Björn Gerdle, Björn O Äng, Wilhelmus J A Grooten, Elena Tseli, Katja Boersma, Britt-Marie Stålnacke, Paul Enthoven, Björn Gerdle, Björn O Äng, Wilhelmus J A Grooten

Abstract

Objectives: This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6 mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).

Materials and methods: Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results: Pain-related factors (intensity and chronicity) were not associated with function/disability at long-term follow-up, odds ratio (OR)=0.84; 95% confidence interval (CI), 0.65-1.07 and OR=0.97; 95% CI, 0.93-1.00, respectively (moderate LoE). A better function at follow-up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07; 95% CI, 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77; 95% CI, 0.65-0.92, low levels of cognitive and behavioral risk factors, OR=0.85; 95% CI, 0.77-0.93 and high levels of protective cognitive and behavioral factors, OR=1.49; 95% CI, 1.17-1.90 (moderate LoE).

Discussion: While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pretreatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.

Figures

FIGURE 1
FIGURE 1
PRISMA flow chart of study selection. HRQoL indicates health-related quality of life; PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.
FIGURE 2
FIGURE 2
Risk of bias within studies as assessed in the 6 domains of the Quality in Prognostic Studies (QUIPS)-tool and presented as total percent of included studies (n=25).
FIGURE 3
FIGURE 3
Pain-related factors: A, Forest plot showing baseline pain intensity and association with positive outcome. B, Forest plot of comparison between pain duration and association with positive outcome. The assessment measures for outcome and prognostic factor (PF) reported and type of analyses are presented in the footnotes. 3A; (1) Outcome: ODI; PF: NRS; univariate; (2) Outcome: COOP-WONCA; PF: VAS; multivariate; (3) Outcome: MPI interference; PF: NRS; univariate; (4) Outcome: QBPDS, relative and absolute recovery; PF: VAS; multivariate. Combined OR; (5) Outcome: RMDQ; PF: NRS average pain intensity past week; zero-order correlations. 3B; (1) Outcome: PDI; PF: pain duration, self reported; (2) Outcome: ODI; PF: pain duration, self reported; (3) Outcome: SF-36 PF; PF: pain duration 0-5 years; multivariate; (4) Outcome: QBPDS, absolute change; PF: pain duration, self reported; (5) Outcome: COPM >2 change; PF: pain duration, self reported. CI indicates confidence interval; COPM, Canadian Occupational Performance Measure; ODI, Oswestry Disability Index; OR, odds ratio; PDI, Pain Disability Index; PF, Physical Functioning; QBPDS, Quebec Back Pain Disability Scale; SF-36, 36-Item Short Form Health Survey.
FIGURE 4
FIGURE 4
Physical Function-related factors: Forest plot of comparison between baseline function and association with positive outcome. The assessment measures for outcome and prognostic factor (PF) reported, type of analyses, and whether estimates (ORs) were combined from plural measures are presented in the footnotes. Physical function (1) Outcome: MPI interference; PF: MPI interference, MPI activity level; uni & multivariate. Combined OR; (2) Outcome: FCI; PF: FCI, univariate; (3) Outcome: RMDQ; PF: RMDQ; univariate zero-order correlations; (4) Outcomes: QBPDS absolute and relative change; PF: SF-36 PCS; multivariate. Combined OR; (5) Outcome: ODI; PF: ODI; multivariate; (6) Outcomes: COPM satisfaction and performance; PF: COPM satisfaction, performance and DRI; multivariate. Combined OR; (7) Outcome: SF-36 PCS; PF: SF-36 PCS; univariate; (8) Outcomes: ODI, SF-36 PF and SF-36 RP; PF: ODI, SF-36 PF, SF-36 RP; multivariate. Combined OR. CI indicates confidence interval; COPM, Canadian Occupational Performance Measure; MMPI, Minnesota Multiphasic Personality Inventory; MPI, Multidimensional Pain Inventory; ODI, Oswestry Disability Index; OR, odds ratio; PF, Physical Functioning; QBPDS, Quebec Back Pain Disability Scale; RP, Role-Physical; SCL-90, Symptom Checklist-90; SF-36, 36-Item Short Form Health Survey.
FIGURE 5
FIGURE 5
Psychological factors: A, Forest plot of comparison between baseline emotional distress and association with positive outcome. B, Forest plot of comparison between baseline levels of cognitive behavioral protective factors and association with positive outcome. C, Forest plot of comparison between baseline levels of cognitive behavioral risk factors and association with positive outcome. The assessment measures for outcome and prognostic factor (PF) reported, type of analyses, and whether estimates (ORs) were combined from plural measures are presented in the footnotes. 5A; (1) Outcome: Activity level; PF: MMPI-Anx Pt; univariate; (2) Outcome: ODI; PF: Zung Self-rated Depression scale; univariate; (3) Outcome: COOP-WONCA; PF: HADS-A and HADS-D; multivariate. Combined OR; (4) Outcome: RMDQ; PF: CES-D; univariate correlation; (5) Outcomes: QBPDS and MISE; PF: Anxiety: MMPI-2 Pt, ANX and PBS and Depression: MMPI-2 D and DEP; multivariate. Combined OR; (6) Outcome: MPI Interference; PF: HADS-A and SCL-90 psychological functioning; multivariate and BDI-II, univariate. Combined OR; (7) Outcomes: QBPDS, relative and absolute recovery; PF: SF-36MCS; multivariate. Combined OR; (8) Outcome: COPM satisfaction; PF: MPI Affective distress: multivariate. 5B; (1) Outcome: MPI Interference; PF: DGSS, Illness coherence, IPQ Personal control, IPQ Treatment control; uni- and multiv. Combined OR; (2) Outcome: FCI; PF: Health optimism; multivariate; (3) Outcomes: COPM Performance and Satisfaction; PF: MPI Life control; multivariate. Combined OR; (4) Outcome: ODI; PF: PSEQ self-efficacy; univariate. 5C; (1) Outcome: RMDQ; PF: CSQ; univariate; (2) Outcomes: QBPDS, MISE; PF: MMPI-2 Hs, MMPI-2 HEA; multivariate. Combined OR; (3) Outcome: ODI; PF: TSK and PCS. Combined OR; (4) Outcome: FCI; PF: Other LoC; multivariate; (5) Outcome: ODI and SF-RP; PF: IPQ-R timeline acute-chronic, BRQ identity, BRQ process expectation; multivariate. Combined OR; (6) Outcome: MPI Interference; PF: IPQ-R; Timeline, Conseq., Emotional repr., Timeline cycl., PSQ, PCS, TSK; uni-and multiv. Combined OR. BDI indicates Beck Depression Inventory; CI, confidence interval; COPM, Canadian Occupational Performance Measure; COOP/WONCA, Coop Functional Health Assessment Charts HADS, Hospital Anxiety and Depression Scale; MISE, Maximal Isometric Strength Extension; MPI, Multidimensional Pain Inventory; ODI, Oswestry Disability Index; OR, odds ratio; PF, Physical Functioning; QBPDS, Quebec Back Pain Disability Scale; RMDQ, Roland-Morris Disability Questionnaire; RP, Role-Physical; SF-36, 36-Item Short Form Health Survey.

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