Dr Sletten Mayo Clinic Pain Rehabilitation Center Review
Mayo Clin Proc Innov Qual Outcomes. 2021 Dec; 5(6): 1056–1065.
Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia
Erica Engelberg-Cook
aDepartment of Pain Medicine, Mayo Dispensary, Jacksonville, FL
Danqing Hu
bMayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, FL
Svetlana Kurklinsky
cHeart for Wellness Sciences, Oklahoma State Academy, Tulsa, OK
Anwar Mack
aDepartment of Hurting Medicine, Mayo Dispensary, Jacksonville, FL
Christopher D. Sletten
aSection of Hurting Medicine, Mayo Dispensary, Jacksonville, FL
Wenchun Qu
aSection of Pain Medicine, Mayo Clinic, Jacksonville, FL
Michael D. Osborne
aDepartment of Pain Medicine, Mayo Clinic, Jacksonville, FL
Abstract
Objective
To analyze opioid intake interference with psychological, well-existence, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Hurting Rehabilitation Program (MCPRP) in Florida.
Patients and Methods
A retrospective study on MCPRP outcomes was conducted. Nosotros reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to make full out a survey at admission to and dismissal from the programme. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Centre for Epidemiological Studies–Depression Calibration, Pain Catastrophizing Scale, 36-Item Short-Form Wellness Status Survey (full general health perceptions subscale), and Pain Cocky-Efficacy Questionnaire. A medical record review identified categories and number of medications at programme admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did non include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group).
Results
Past dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a meaning (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially college pct in the opioids group.
Conclusion
Benefit of the comprehensive pain rehabilitation programme in patients with fibromyalgia was indicated past clinical improvements in hurting severity, physical and emotional health, and functional chapters while successfully tapering medication. Opioid intake at admission may modify the program outcomes.
Abbreviations and Acronyms: CESD, Center for Epidemiological Studies–Depression Scale, CSS, cardinal sensitization syndrome, FM, fibromyalgia, MCPRP, Mayo Clinic Comprehensive Pain Rehabilitation Program, MPI, Multidimensional Hurting Inventory, NO, no opioids on admission, NSAID, nonsteroidal anti-inflammatory drug, OME, oral morphine equivalent, OP, opioids on admission, PCS, Hurting Catastrophizing Scale, PSEQ, Hurting Self-Efficacy Questionnaire, SF-36, 36-Item Brusque-Class Health Status Survey, SS, Symptom Severity Calibration, WPI, Widespread Pain Index
Fibromyalgia (FM) is a complex hurting disorder that can be challenging to diagnose, in role because the pathophysiologic underpinnings have nonetheless to exist fully understood.1 Prevalence is at 2% in the United States, similar to that of the world's population.two Late diagnosis is associated with a large number of medication prescriptions that are frequently ineffective (or potentially counterproductive) to patient care, specifically, opioids and benzodiazepines. Nonsteroidal anti-inflammatory drugs (NSAIDs) and additional over-the-counter self-medication and supplements are eventually used with express efficacy.3 Mayo Clinic offers a 3-week outpatient Mayo Dispensary Comprehensive Pain Rehabilitation Program (MCPRP) that provides cerebral-behavioral interdisciplinary intervention to patients with multiple chronic pain conditions, including FM.four,5 The MCPRP utilizes self-study validated questionnaires as diagnostic tools for chronic hurting syndrome, provides physical and occupational therapy, and medical and psychological support with active medication tapering.vi Of notation, evidence-based effectiveness of pain rehabilitation addresses physical, psychological, and cognitive outcomes along with medication tapering.
Background
The prevalence of FM is 0.5% to v% in the general population, depending on the diagnostic/classification criteria used and the population analyzed.7 Fibromyalgia is essentially debilitating, characterized by widespread musculoskeletal hurting, fatigue, sleep disturbance, cognitive difficulties, and centrally mediated pain distension,8 frequently overlapping with cardinal sensitization syndrome (CSS).iii It occurs in both sexes and all ages, although it was previously thought to occur most normally in middle-aged women (58.7% of cases).9 Patients written report generalized chronic pain10 for at to the lowest degree iii months with cognitive deficits that may include memory and attention bug. The wide variety of symptoms and associated comorbidities often lead to a complex and delayed diagnosis.xi Patients with FM take a loftier rate of disability, with more than seventy% of patients self-reporting work disability compared to 19% in the full general population.12
Over the years, the status has been called various terms such as neurastheniaxiii and fibrositis in the 1930s, until it was finally named fibromyalgia in 1990 past the consensus criteria established by American College of Rheumatology (ACR) preliminary criteria, revised in 201014 and modified in 2011 and 2016.15 The American College of Rheumatology 2010 diagnostic criteria eliminated the tender point exam and recommend use a symptom-based diagnostic cess through the Widespread Pain Index (WPI) and the Symptom Severity Scale (SS).14 Symptomatology is characterized by allodynia and hyperalgesia, and the precise underlying pathophysiology is not entirely elucidated.xvi Information technology is ordinarily associated with concomitant small-scale fiber neuropathy (40% to l%)17 and linked to hyperexcitability of the nociceptive system that ultimately results in central amplification known as CSS,eighteen,19 characterized by a disrupted somatosensory indicate processing.19 Interestingly, endogenous opioidergic action is increased in FM with consequent opioid receptor down-regulation, which partially explains why opioid therapy is ineffective.20
Fibromyalgia is associated with fatigue, poor sleep, cerebral deficits, headaches, anxiety, and depression with a wide range of somatic symptoms.three These comorbidities are frequently constitute in conditions such as chronic fatigue syndrome, irritable bowel syndrome, and a new spectrum of unexplained conditions that would eventually reflect underlying CSS.21 In a chronic pain population, 2% to twoscore% (hateful, 15%) of patients develop CSS,22 particularly in FM patients with related psychopathologic conditions, which have been termed functional syndromes,23 medically unexplained symptoms,24 and bodily distress syndrome.25 Central sensitization syndrome is a neurophysiologic condition that increases neuroexcitability of dorsal horn neurons by increased synaptic transmission and reduces inhibition,26 in which specific encephalon areas, the periaqueductal grayness matter and the rostral ventromedial medulla, play a critical office.27 Functional, structural, and chemical changes in the key nervous system28 somewhen modify the sensory, emotional, and modulatory circuits that usually inhibit pain,29 which underlies increased hurting sensitivity associated with hyperalgesia and/or allodynia.27,30
Polypharmacy is common in the chronic pain population31 every bit a outcome of these patients' chronic status and frequent comorbidities. Patients are prescribed several medications and accept numerous over-the-counter drugs and supplements.32 This practice is not only inappropriate but also increases the take a chance of drug corruption, interactions, adverse events, and gamble of hospitalization.31 Pharmaceuticals prescribed for FM include a heterogeneous group of medications mayhap best collectively termed neuromodulatory medications. Currently, there are 3 US Food and Drug Administration–approved medications for FM: pregabalin (gabapentinoid, voltage-gated calcium aqueduct subunit ligand), duloxetine (selective serotonin and norepinephrine reuptake inhibitors), and milnacipran (serotonin-norepinephrine reuptake inhibitor). Tricyclic antidepressants and muscle relaxants are often prescribed, although non specifically approved by the U.s. Food and Drug Assistants for FM. Gabapentinoids have been found to amend pain,33 quality of slumber, and fatigue,34 and tricyclic antidepressants tin improve pain, slumber, and bowel and float symptoms.35 Serotonin-norepinephrine reuptake inhibitors can assistance with fatigue.35 A recent written report on the pharmacological patterns of medication use in FM found that frequently prescribed drugs were tramadol (40%) and benzodiazepines (30%) and, to a lesser extent, duloxetine (22%), pregabalin (19%), amitriptyline (17%), NSAIDs (sixteen%); with seven.v% of participants under opioids prescription.36 Additionally, it was shown that tapper off higher doses of opioids requires longer flow of time, that the elapsing of opioid use does non affect the length of tapering efforts, and that effectiveness of tapering without adjuvants is succesful when combined with cognitive behavioral strategies used in pain rehabilitation programs.37 Nonpharmacologic strategies based in a cognitive behavioral arroyo eventually contribute to better outcomes,37,38 with a positive effect on pain, mood, self-efficacy reducing the number of physician visits, medications taken,39 and higher rate of return to piece of work.40
To access psychological, well-being, and functioning self-reported outcomes likewise every bit the effectiveness of medication tapering at completion of our rehabilitation program, we reviewed 150 cases of FM seen in our practice in one year menstruation (2014 to 2015), to compare outcomes of patients admitted with or without daily opioid intake.
Patients and Methods
This study was approved by the Mayo Clinic Institutional Review Board (IRB No. 14-002517).
Study Participants
The retrospective study collected data from patients with FM who completed the 3-calendar week MCPRP from May 1, 2014, to May 1, 2015, in Florida. All patients 18 years old or older with a prior diagnosis of FM, articulate impairment in daily operation, deconditioning, and an interest/credence of the demand for pain rehabilitation were included in the plan. Additionally, patients were excluded when the minimal criteria from the WPI and SS scales were not met. Participants were divided in 2 groups: patients who were admitted to the program with no daily opioid intake (NO) and patients who were admitted with any daily dosage of opioids (OP).
Treatment
The MCPRP is a iii-calendar week handling regimen for patients with intractable FM when other standard-of-care options have been exhausted.4,41 The MCPRP has an accent on physical reconditioning, occupational therapy, cognitive-behavioral interventions, and medication weaning and management that takes place over more than 100 hours. Physical therapy aims to utilize moderate physical reconditioning to improve action tolerance despite symptoms. Occupational therapy provides tools to teach and utilise the concepts of moderation, fourth dimension management, and appropriate activity modification. Cerebral-behavioral therapy grouping sessions, led by a pain psychologist, accost the behavioral, cognitive, and emotional comorbidities of chronic pain. Physicians, md assistants, and nurses provide medical oversite for medication tapering of all symptom-targeted pharmacological treatments.
Report Measurements
Concomitant Medications
On enrollment in the MCPRP, patients provide a detailed list of their current medications. All opioid medications and almost medications are actively tapered during the program, regardless of patient motivation to do so (excluding anticonvulsants and antidepressants used every bit neuromodulators of chronic hurting) every bit a standard exercise of the MCPRP.
Pain Scores and Cocky-Reported Questionnaires
Patients in the MCPRP were asked to answer figurer-based surveys recorded using the Inquiry Electronic Data Capture (REDCap) system, version 7.4.23,42 hosted on the institutional internal server. REDCap surveys used in this written report included the Numeric Pain Rating Calibration,43 Multidimensional Hurting Inventory (MPI),44 36-Particular Curt-Grade Wellness Status Survey (SF-36),45 Center for Epidemiological Studies–Depression Calibration (CESD),46 Pain Catastrophizing Calibration (PCS),47 and Pain Self-Efficacy Questionnaire (PSEQ),48 and the system too gathered patient demographic data.
Statistical Analyses
Mean scores difference was analyzed using paired 2-sided t tests to evaluate questionnaire outcomes and pain scores. Categorical variables were compared using 2-sided χii tests and t tests to compare means. All group comparisons were performed using an analysis of variance followed past the Tukey exam. Frequency distribution analysis was used to evaluate demographic characteristics and medications. All statistical analyses were performed using GraphPad Prism, version 9.0.0. The results were considered statistically significant at P=.05; we used 95% CIs.
Results
Among the 256 patients who completed the MCPRP from May ane, 2014, to May 1, 2015, 195 satisfied inclusion criteria (WPI and SS scales), 45 of whom were excluded because of no FM diagnosis. Baseline demographic characteristics of the 150 included participants are presented in Table 1. Near of the patients were women (lxx.1% to 75.3%), married (71.ii% to 72.seven%), unemployed (79.5% to 81.8%), and White (79.5% to 94.eight%) and had an average of eleven years of chronic hurting. The number of patients observed in both groups was similar: 73 of 150 patients (48.7%) in the NO group and 77 (51.3%). The OP group had significantly more White patients (73 of 77 [94.8%]) and fewer African American patients (ii of 77 [2.6%]) than the NO grouping (58 of 73 [79.5%] White and 12 of 73 [16.4%] African American; P=.02). This observation may reverberate nationally published data showing that women and Whites are more prone to opioid addiction.49
Tabular array ane
Demographic Characteristics of the Written report Populationa
| Variable | No opioids grouping (Due north=73) | Opioid group (N=77) | P value |
|---|---|---|---|
| Sex | .47 | ||
| Male person | 18 (24.7) | 23 (29.9) | |
| Female | 55 (75.three) | 54 (seventy.i) | |
| Age (y) | 50.vii±14.1 | 49.vii±13.7 | .56 |
| Marital conditionb | .37 | ||
| Married | 52 (71.2) | 56 (72.7) | |
| Unmarried | 12 (16.iv) | 10 (13.0) | |
| Divorced | 0 (0.0) | 3 (iii.nine) | |
| Separated | 6 (8.2) | 7 (nine.1) | |
| Employment status | .71 | ||
| Employed | fifteen (20.v) | xiv (18.two) | |
| Unemployed | 58 (79.5) | 63 (81.8) | |
| Race | .02 | ||
| White | 58 (79.v) | 73 (94.8) | |
| African American | 12 (16.4) | ii (2.6) | |
| Asian | 0 (0.0) | 1 (ane.3) | |
| Other | three (4.1) | ane (i.3) | |
| Average pain duration (y) | 10.8±9.iii | xi.half dozen±x.0 | .53 |
The boilerplate numeric pain score on access was half dozen.40 in the NO group and 6.52 in the OP grouping, and these scores were reduced to 4.67 and 5.ten, respectively, at dismissal (P<.0001), which represents 27.0% comeback in the NO group and 21.8% in the OP group (Table ii). At dismissal, all questionnaire outcomes significantly improved in both groups (all P≤.0008). Pregnant improvements were found in MPI scores (P<.0001 for both NO and OP groups) for perceived control (NO, 24.two%; OP, 21.one%) and interference of pain (NO, 12.7%; OP, 8.2%). Improvement of 26.viii% (NO) and 28.4% (OP) in SF-36 and PSEQ in functioning and health perception (P<.0001) may reverberate health perception, functioning, and socializing. Peculiarly for PSEQ, comeback reached 72.eight% in the NO grouping compared to 43.ix% in the OP grouping, indicating a tendency for better outcome in the NO group (P=.08). Improvements in scores for the PCS (NO, 35.3%; OP, 27.vi%) and CESD (NO, 42.6%; OP, 34.ane%) indicate substantial decreases in depressive symptoms and negative pain-related cognitions. Overall, the results highlight the effectiveness of the MCPRP to improve hurting perception, functioning, and well-existence and raises the question of whether the tendency for meliorate outcomes in NO patients may be related to negative-event polypharmacy. We observed that the OP group took a larger number of medications both at admission and dismissal compared to the NO group (P<.0001; Table iii).
Table 2
Self-Reported Calibration Scores and Percentage of Comebacka , b
| Consequence scale | Group | Admission score | Discharge score | Score deviation | Paired 2-sided t values (df) | P value | % Improvement |
|---|---|---|---|---|---|---|---|
| NRS | NO | six.40±i.63 | 4.67±two.33 | −1.73±0.33 | −v.15±144 | <.0001 | 27.0 |
| OP | 6.52±1.86 | 5.x±ii.38 | −1.38±0.35 | 3.921±152 | <.0001 | 21.8 | |
| MPI | |||||||
| Perceived control | NO | 46.65±8.44 | 57.92±ix.04 | 11.27±1.46 | 7.73±144 | <.0001 | 24.two |
| OP | 47.62±8.17 | 57.67±viii.52 | 10.69±ane.35 | vii.90±152 | <.0001 | 21.1 | |
| Interference of pain | NO | 53.92±five.72 | 47.06±ii.33 | −6.87±1.21 | −5.67±144 | <.0001 | 12.seven |
| OP | 52.02±half dozen.81 | 47.74±8.85 | −4.33±1.26 | three.42±152 | .0008 | eight.2 | |
| SF-36, general health perception | NO | 34.11±12.25 | 43.25±12.34 | 9.48±2.04 | 4.66±143 | <.0001 | 26.8 |
| OP | 35.38±11.31 | 45.43±11.50 | 10.28±1.85 | 5.57±152 | <.0001 | 28.4 | |
| CESD | NO | 26.01±12.07 | 14.95±xi.52 | −11.07±ane.97 | v.63±144 | <.0001 | 42.6 |
| OP | 25.49±11.81 | xvi.81±13.09 | −9.31±1.10 | 4.66±152 | <.0001 | 34.i | |
| PCS | NO | 26.55±10.33 | 17.xviii±10.38 | −ix.37±i.73 | −5.43±144 | <.0001 | 35.iii |
| OP | 25.23±9.98 | eighteen.27±12.00 | −6.91±i.84 | 3.75±152 | .0003 | 27.6 | |
| PSEQ | NO | 26.16±12.61 | 45.21±12.18 | 19.04±2.07 | 9.22±144 | <.0001 | 72.8 |
| OP | 29.92±12.27 | 43.04±12.50 | 13.78±2.01 | 6.87±152 | <.0001 | 43.nine |
Table 3
Number of Medications Used in No Opioids and Opioids Groupsa , b
| Variable | No opioids group | P value | Opioids group | P value | ||
|---|---|---|---|---|---|---|
| Access | Dismissal | Admission | Dismissal | |||
| Anticonvulsants | 0.36±0.616 | 0.xiii±0.42 | .09 | 0.71±0.65 | 0.17±0.461 | <.0001 |
| Antidepressants | 1.81±0.696 | 1.0±0.173 | <.0001 | one.84±0.752 | 1.05±0.265 | <.0001 |
| Barbiturates | 0.06±0.237 | 0.04±0.207 | .97 | 0.02±0.153 | 0.04±0.187 | .98 |
| Benzodiazepines | 0.31±0.495 | 0.66±0.65 | .001 | 0.03±0.17 | 0.02±0.fifteen | <.0001 |
| Stimulants | 0.01±0.121 | 0.01±0.121 | .99 | 0.08±0.387 | 0.08±0.387 | .99 |
| Triptans | 0.xvi±0.409 | 0.06±0.293 | .32 | 0.12±0.361 | 0.07±0.339 | .82 |
| Cannabinoids | 0 | 0 | NA | 0.02±0.153 | 0.02±0.153 | .35 |
| NSAIDs | 0.81±0.885 | 0.48±0.72 | .09 | 0.92±0.934 | 0.57±0.68 | .03 |
| Opioids | 0 | 0 | NA | 1.4±0.76 | 0.thirteen±0.422 | <.0001 |
| Corticosteroids | 0.04±0.207 | 0.01±0.121 | .77 | 0.07±0.259 | 0 | .05 |
| Antiemetics | 0.xiii±0.42 | 0.16±0.476 | .98 | 0.36±0.593 | 0.34±0.566 | .99 |
| Antispasmodics | 0.09±0.286 | 0 | .07 | 0.07±0.302 | 0 | .12 |
| Muscle relaxants | 0.16±0.507 | 0.10±0.306 | .89 | 0.42±0.54 | 0.35±0.525 | .77 |
| Supplements/vitamins | 1.72±two.265 | 0.37±0.944 | .0004 | 2.eleven±2.574 | 0.41±ane.271 | <.0001 |
| Topical | 0.16±0.409 | 0.19±0.395 | .99 | 0.46±0.664 | 0.43±0.715 | .99 |
| Full No. of medications | 7.33±3.405 | three.85±1.91 | <.0001 | 10.seven±4.179 | half-dozen.4±2.879 | <.0001 |
| Total OMEs | 0 | 0 | NA | 60.33±65.82 | ii.14±7.95 | <.0001 |
| Full LMEs | 0.65±1.349 | 0.09±0.728 | .35 | 2.23±3.441 | 0.17±0.717 | <.0001 |
On access, 77 of the 150 patients (51.3%) were taking opioid medications, with the average of sixty.33 mg oral morphine equivalents (OMEs) per 24-hour interval, ranging between 5 mg and 340 mg OMEs per day. Among the 77 patients in the OP group, opioids were not tapered in 5 (six.v%); nonetheless, the dose was reduced past 84%. One patient was excluded from the OME calculation because of the presence of an intrathecal fentanyl delivery system with a continuous rate of 200 μg/d (OME, 6000 mg/d), which was considered a statistical outlier for OME calculation. By the finish of the programme, this patient's intrathecal fentanyl dose was weaned to 190 μg/d (OME, 5700 mg/d).
The frequency of patients taking various classes of major medications and the medium number of medications taken reveal polypharmacy in our patients (Tabular array 3, Table 4). In both the OP and NO groups, the number of patients taking antidepressants (P<.0001), benzodiazepines (P<.0001), and supplements/vitamins (P=.0004 and P<.0001, respectively), were significantly reduced at dismissal. Additionally, in the OP group, anticonvulsants (P<.0001), NSAIDs (P=.003), opioids (P<.0001), and muscle relaxants (P<.0001) were similarly reduced, suggesting a larger number of medications tapered (P<.0001). In addition, lorazepam milligram equivalents were significantly reduced in the OP group (P<.0001), In the NO group, lorazepam milligram equivalents were not reduced, which is possibly related to less benzodiazepine intake at access. Specifically, in the OP group, medication reduction occurred in anticonvulsants, antidepressants, musculus relaxants, opioids, NSAIDs, and supplements/vitamins at dismissal compared to the NO group in which reductions were observed in antidepressants, benzodiazepines, and supplements/vitamins only. In addition, the greater the number of full medications on admission (indicating more than severe polypharmacy) was associated with better improvement in PSEQ score (P=.01). Patients taking antiemetics on admission had better comeback in CESD (P=.01), MPI-life (P=.05), and PSEQ (P=.007). Patients taking muscle relaxants on admission had better improvement in SF-36 health perception (P=.02). Patients non taking supplements/vitamins on admission had amend improvement on MPI-life at dismissal from the MCPRC (P=.04). The Effigy illustrates these differences.
Tabular array four
Median Number of Medications Takena
| Medications | Admission | Dismissal | Wilcoxon signed rank exam σ | P value |
|---|---|---|---|---|
| Total medications | 12 (seven-19) | 8 (v-12) | 5623.5 | <.0001 |
| Antidepressants | 2 (i-2) | 1 (0-1) | 4830 | <.0001 |
| Supplements/vitamins | 1 (0-3) | 0 (0-0) | 4625.5 | <.0001 |
| Musculus relaxants | 0 (1-0) | 0 (0-0) | 657 | .0024 |
Number of medications taken at admission (kickoff column of each grouping) and dismissal (second column) in group with no daily (OP) opioids intake compare to group with any dosage of daily opioid intake (OP) on admission. Number of asterisks indicate the level of significance. LME, lorazepam milligram equivalent; OME, oral morphine equivalent.
Word
Overall, the results of our study indicated benign outcomes later on the 3-week MCPRP. The self-reported pain scores improved virtually 22% in the OP grouping and 27% for the NO group of patients. At the MCPRP at Mayo Dispensary in Rochester, Minnesota, historical outcomes have been reported at 27.8% improvement in pain scores for patients taking opioids daily and 24.6% comeback in pain scores for patients non taking opioids.37 Our results revealed better improvement in the NO group than in the OP grouping. Earlier studies found that daily opioid intake may be associated with greater comorbidities and psychiatric and substance abuse disorders and negatively impact self-reported scores.l Taper methodology is tailored for each private patient, contained of opioid dosage, and allows pain-related score improvement regardless at program completion.37 1 of the highlights of the MCPRP is that medication is actively tapered, even in reluctant patients, accompanied by a remarkable comeback in self-reported scores.51 Although the total number of medications was substantially reduced in both groups (from seven.33 to 3.85 in the NO group and from 10.7 to 6.4 in the OP grouping), that reduction is likely related a college number of prescribed medications in the OP group. This finding farther highlights the negative influences of polypharmacy and opioid intake, and supports a possible demand for a specific therapeutic strategy in this group. Although combined drug therapy may be beneficial for patients with chronic pain, bear witness of the opposite effect is concerning.52
Patients with FM have increased risk for development of depression and anxiety53,54 related to opioid prescription.55 The literature has revealed improvement in depressive symptoms from minor to normal scores.56 At admission, our patients had worse CESD scores compared with those reported in the literature (NO, 26.01; OP, 25.49).50 All the same, dismissal CESD score improvement was remarkable (xv.6), indicating a successful program regardless of admission scores.
Catastrophizing in patients with chronic hurting is linked to higher pain intensity, higher disability, and psychological distress.57 It is associated with increased activity in several encephalon areas related to limbic, emotional, motor, and attentional aspects, altering hurting perception, attention, and anticipation.58 In our written report, PCS scores decreased (NO, 35.three%; OP, 27.6%), ranging from 17.eighteen to eighteen.27, but they remain college compared with the general population (13.87)59 and in chronic pain populations (NO, 26.01; OP, 25.49) vs 22.three reported in the literature.59 In improver, patients in our NO grouping tended to have a better score comeback, which may be related the negative consequence of opioids and polypharmacy.
Perception of global health reflects overall perception of health, well-being, and performance measured by the SF-36.60 Admission scores in our study were 34.xi in the NO grouping and 35.38 in the OP group, with a mean score comeback to ix.48 (NO) and x.28 (OP) by dismissal correlated with clinically positive outcomes. A previously reported SF-36 mean score for FM was 54.iv.61 Our OP group tended to accept better comeback in global health perception (28.four%) than our NO group (26.8%). This observation is relevant for patients taking opioids at admission because this group has higher scores of depression and pain catastrophizing.
The average perceived life control in our patient population was lower (47.1) at admission compared with that reported in the literature (49.2).62 Perceived life control improved 24.2% (NO) and 21.1% (OP), remaining at higher levels compared with other studies.63 For pain interference, our patients' admission scores were 53.92 (NO) and 52.02 (OP) and decreased to 47.06 (NO) and 47.74 (OP), while improvements reported in the literature were as low as 43.51,63 However, there was a pregnant improvement in our patients, both statistically and clinically.
The PSEQ covers a range of functions, including household chores, socializing, and work too equally coping with pain without medication. Higher self-efficacy is associated with fewer hurting behaviors64 and less concrete impairment65 in patients with FM, with an average score of 25.5.48 Our results revealed improvements from 26.16 to 45.21 (NO) and 29.92 to 43.04 (OP). Patients in the NO group had a remarkable 72.8% improvement (P<.0001). With exception of SF-36 score, patients in our NO group had greater benefits than the OP group, which may indicate difficulties regarding benefit from the program in patients taking opioids on admission.
Polypharmacy is highly prevalent in FM, contributes to exacerbation of symptoms, and may prompt decreased benefits from the MCPRP.37 Optimized pharmacological therapy along with physical and emotional aspects are promoted by the MCPRP and proven to exist benign to patients.2,66 The number of medications was effectively tapered, particularly decreasing the number of opioids (91.1%) with a reduction of 96.5% OME, benzodiazepines (NO 86.3%; OP 92.2%), and supplements/vitamins (NO 78.3%; OP fourscore.half dozen%), while patients concomitantly experienced clinical comeback is multiple domains (Effigy). To a smaller extent, the number of NSAIDs, muscle relaxants, and triptans were also actively reduced. Particularly in FM, polypharmacy potentially contributes to burdensome agin furnishings such every bit sedation and physical and psychological dependence, and fifty-fifty when documented to be ineffective in relieving pain and improving office, many patients observe themselves without a pragmatic option for cessation without symptom exacerbation. Nevertheless, this study adds evidence to the effectiveness of the MCPRP models, and regardless of differences among them, the interdisciplinary, team-based functional restoration delivers remarkable comeback to patients with chronic pain and is also efficient in tapering medications, which farther contributes to better outcomes. Our OP grouping had 7 dissimilar medication categories tapered compared with four categories tapered in the NO group. This represent an reduction of xl.2% in the OP grouping and 47.5% in the NO group in full number of medication tapered. In addition, but vii of 77 (9.1%) OP patients were non weaned off opioids past the end of the program. Taken together, these results confirm the program efficacy, and, particularly in OP patients, more medications were tapered, regardless of a lower psychological and operation score improvement. This finding may suggest the negative effects of opioids and polypharmacy in patients with FM. Cognitive disfunction and psychological status is knowingly influenced by opioid intake.2,67
Conclusion
Patients with FM experience clinical improvements in hurting severity, physical and emotional health, and functional capacity when treated with a comprehensive hurting rehabilitation program improving quality of life and facilitating a return to regular daily activities. Notably, these improvements tin can occur while patients concomitantly undergo systematic medication tapers, including opioids. Patients who started the MCPRP non taking opioids daily achieved better outcomes by the stop of the program suggesting that the group of patients taking opioids at admission may benefit of a grouping-specific direction.
Footnotes
Grant Support: The work was supported by Section of Pain Medicine, Mayo Clinic Jacksonville.
Dr Mack is now with Nevada Pain & Spine Specialists, Reno.
Potential Competing Interests: The authors report no competing interests.
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