Challenges to early prevention and intervention: personal experiences with adherence.

OBJECTIVE: To describe potential adherence-related difficulties encountered in the implementation of a secondary prevention, early intervention study with acute low back pain patients. An additional goal is to provide recommendations, based on the authors' experience, on how best to overcome these potential obstacles for future research. DESIGN: The study used a predictive algorithm, identified through previous research, to identify which patients presenting with acute low back pain were at risk for developing chronic problems. These subjects were then treated prophylactically with an interdisciplinary intervention. Specific difficulties initially encountered during the pilot stage of implementation of this intervention included securing adequate physician referrals to the study and helping patients to progress through treatment in the most efficient manner. CONCLUSIONS: Potential difficulties are discussed in the contextual framework of treatment adherence and factors affecting it, including the impact of personality factors, satisfaction, comprehension, side effects, financial issues, length of treatment, type of regimen, social issues, patient beliefs, and biologic factors. It is hoped that the present authors' experience will enable future investigators to anticipate these common problems, and structure their research endeavors accordingly.

Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study.

In an attempt to prevent acute low-back pain from becoming a chronic disability problem, an earlier study developed a statistical algorithm which accurately identified those acute low-back pain patients who were at high risk for developing such chronicity. The major goal of the present study was to evaluate the clinical effectiveness of employing an early intervention program with these high-risk patients in order to prevent the development of chronic disability at a 1-year follow-up. Approximately 700 acute low-back pain patients were screened for their high-risk versus low-risk status. On the basis of this screening, high-risk patients were then randomly assigned to one of two groups: a functional restoration early intervention group (n = 22), or a nonintervention group (n = 48). A group of low-risk subjects (n = 54) who did not receive any early intervention was also evaluated. All these subjects were prospectively tracked at 3-month intervals starting from the date of their initial evaluation, culminating in a 12-month follow-up. During these follow-up evaluations, pain disability and socioeconomic outcomes (such as return-to-work and healthcare utilization) were assessed. Results clearly indicated that the high-risk subjects who received early intervention displayed statistically significant fewer indices of chronic pain disability on a wide range of work, healthcare utilization, medication use, and self-report pain variables, relative to the high-risk subjects who do not receive such early intervention. In addition, the high-risk nonintervention group displayed significantly more symptoms of chronic pain disability on these variables relative to the initially low-risk subjects. Cost-comparison savings data were also evaluated. These data revealed that there were greater cost savings associated with the early intervention group versus the no early intervention group. The overall results of this study clearly demonstrate the treatment- and cost-effectiveness of an early intervention program for acute low-back pain patients.

Motivation for treatment preceding and following a substance abuse program.

BACKGROUND: Motivation for treatment is generally considered a powerful predictor of treatment seeking and success in patients with alcohol and drug dependence disorders. Objective measures have seldom been used, however, to assess how motivation is altered during treatment, or the impact of depression/anxiety on motivation. METHODS: We assessed motivation using the Treatment Motivation Questionnaire (TMQ) in 78 male alcohol- and drug-dependent veterans immediately preceding and following an intensive, 2-week residential substance abuse program. The TMQ assesses four domains of motivation: internal motivation, external motivation, interpersonal help-seeking, and nonconfidence in treatment. RESULTS: Following treatment, only external motivation changed (decreased), whereas the other dimensions of motivation retained the high levels observed pretreatment. Depression (as measured by the Beck Depression Inventory, BDI) was highly correlated with three of the four domains of motivation, while anxiety (as measured by the Spielberger State-Trait Anxiety Inventory, STAI) was highly correlated solely with internal motivation. CONCLUSIONS: Our findings suggest that depression and anxiety may differentially effect motivation and that external motivation may be quite transient; treatment implications of these findings are discussed. The usefulness of the TMQ in a residential population was also explored.

A preliminary study of multidimensional pain inventory profile differences in predicting treatment outcome in a heterogeneous cohort of patients with chronic pain.

OBJECTIVE: The objective was to evaluate whether the Multidimensional Pain Inventory (MPI) is effective for predicting response to interdisciplinary treatment in a heterogeneous group of patients with chronic pain. Changes in patients' profiles to a predominantly adaptive coping status after treatment also were assessed. DESIGN: A prospective study was conducted of patients with an array of pain conditions. A standard evaluation battery, including measures of self-reported pain and disability, psychosocial functioning, helpfulness of the program, and medication use, was used for all patients before and after treatment. The MPI status of patients was evaluated and differential response to treatment was assessed. METHODS: Sixty-five consecutive patients with chronic pain were evaluated before and immediately after participation in an interdisciplinary pain treatment program. This heterogeneous pain-condition cohort was also differentiated on the basis of the MPI to evaluate potential differential response to treatment. RESULTS: Results revealed significant improvement among these patients with chronic pain when a comprehensive interdisciplinary pain-management program was administered. This improvement was seen across the variety of outcomes evaluated, including narcotic medication use. Most important, the MPI subgroup classification did not significantly predict the degree of positive treatment outcome; all subgroups improved. CONCLUSIONS: Although there were major differences in psychosocial functioning before treatment, the MPI was not found to significantly predict response to interdisciplinary treatment in a heterogeneous group of patients with chronic pain. Thus, a comprehensive interdisciplinary treatment program may achieve its full effectiveness across a wide array of pain/disability-related outcome variables, regardless of initial MPI profile categorization.