Pain rehabilitation in Sweden : a quality registry study

Sammanfattning: Background: Chronic pain, defined as non-malignant pain emanating from the musculoskeletal system, may limit everyday activities, social functioning and the quality of social and working life for individuals, creating disability as well as incurring high economic and public costs for society. Controlled studies show that cognitive-behavioural interdisciplinary rehabilitation has a positive effect on functioning in patients who have been disabled by chronic non-malignant pain conditions. Positive outcomes described include lower pain intensity, less preoccupation with pain, greater independence and lower consumption of healthcare. On the other hand, the return to work rate varies. To facilitate comparisons on the national level and to enable audit spirals for single programmes as part of the ongoing quality assurance in healthcare the Swedish Quality Registry for Pain Rehabilitation (SQRP) has aggregated data since 1998 on all patients referred to the majority of Swedish rehabilitation units. The aim of this dissertation was to improve the knowledge base of pain rehabilitation in Sweden using the validated self-reported instruments of pain and its consequences included in the SQRP. Methods: The SQRP data were collected before, at the end and 1 year after the intervention for all individuals included, and concerns self-reported demographic variables, pain intensity, activities, thought patterns, impact of pain on daily life and life satisfaction. Individual sick leave data were collected from the Swedish Social Insurance after 1 year. Data collected from 19833 patients (6002 men and 13831 women) of which 7289 participate in work ability improving programmes, were used. Results: The results of four studies included in this thesis showed that the SQRP provided a basis for scientific works since it use the validated self-report instruments of pain and its consequences and contain a large amount of patient’s data. However, a lack of follow-up data from some units influenced the opportunity of to analyse long-term outcomes. Nevertheless, the SQRP was a useful tool to audit and evaluate as well as to propose optimising of pain rehabilitation. It seemed that contextual factors such as patients’ own beliefs and expectations, education, gender, actual sick leave and employment situation had more importance for the effect of rehabilitation programme than pain characteristics, depression or activity limitation. The Multidimensional Pain Inventory (MPI) scale scores and MPI coping profiles might be used for assessing the outcomes of treatment interventions. A reduction of MPI scale scores for Pain severity and Interference decreased the risk of being on full-time sick leave. On the other hand, the MPI coping profiles Dysfunctional, among both men and women, and Interpersonally distressed, among women, were associated with higher odds of being on full-time sick leave. Conclusions: Attending cognitive-behavioural interdisciplinary pain rehabilitation programmes in Sweden resulted in improvements of the MPI scales after completing a pain rehabilitation programme and this improvement was sustained after 1 year. Moreover, these programmes decreased the levels of full-time sick leave 1 year after completed programme. The findings suggest also the need to tailor rehabilitative strategies differently for men and women as well as for different pain coping profiles.