IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Rationale, design, and implementation protocol of the Dutch clinical practice guideline Pain in patients with cancer: a cluster randomised controlled trial with short message service (SMS) and interactive voice response (IVR) Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain The secondary prevention of low back pain: a controlled study with follow-up Screening to Identify Patients at Risk: Profiles of Psychological Risk Factors for Early Intervention Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults [ISRCTN11899548] Preventing chronic postsurgical pain: how much of a difference makes a difference? [Psychological mechanisms in the transition from acute to chronic pain: over- or underrated?]. Comparing the clinical-effectiveness and cost-effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) intervention with a waiting list control among adults with chronic pain: study protocol for a randomised controlled trial Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial Results of a randomized controlled pilot study of a self-management intervention for cancer pain. A controlled study of the effects of an early intervention on acute musculoskeletal pain problems Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care. Determining the effectiveness of a clinical‐practice intervention in improving the control of pain in outpatients with cancer Randomized clinical trial of an intensive nursing-based pain education program for cancer outpatients suffering from pain Chronic pain self-management for older adults: a randomized controlled trial [ISRCTN11899548] A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement.
Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) Background One-half of patients with cancer have pain .  In nearly one out of two cancer patients with  pain , this was undertreated . Inadequate pain control still remains an important problem in this group of patients . Therefore , in 2008 a national , evidence -based multidisciplinary clinical practice guideline ' pain in patients with cancer ' has been developed . Yet , publishing a guideline is not enough . Implementation is needed to improve pain management . An innovative implementation strategy , Short Message Service with Interactive Voice Response ( SVS-IVR ) , has been developed and pilot tested . This study aims to evaluate on effectiveness of this strategy to improve pain reporting , pain measurement and adequate pain therapy . In addition , whether the active role of the patient and involvement of caregivers in pain management may change . Methods / design A cluster r and omised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherl and s , with three hospitals in the intervention and three in the control condition . Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention . The intervention includes training of professionals ( medical oncologists , nurses , and general practitioners ) and SMS-IVR to report pain in patients with cancer  to improve pain reporting by patients , pain management by medical oncologists , nurses , and general practitioners , and decrease pain intensity . Discussion This innovative implementation strategy with technical tools and the involvement of patients , may enhance the use of the guideline ' pain in patients with cancer ' for pain management . Short Message Service alerts may serve as a tool to support self-management of patients . Therefore , the SMS-IVR intervention may increase the feeling of having control over one 's life . Trail registration Netherl and s Trial Register ( NTR ) : & NA ; Although chronic pain is a frequent cause of suffering and disability and is costly to society , there continues to be limited access to specialty pain clinic services . Hence , there is a need for cost‐effective , accessible interventions that will help people find ways to better manage this difficult problem . This r and omized controlled trial examined the effect of a low‐cost , community‐based , nurse‐delivered , group psychoeducation program entitled the Chronic Pain Self‐Management Program ( CPSMP ) . It has a st and ard protocol that was modified from the successful Arthritis Self‐Management Program ( ASMP ) . One hundred and ten individuals with mixed idiopathic chronic pain conditions were enrolled in the study ( 75 % female ; mean age 40 years ; mean chronicity 6 years ) and were r and omly assigned to one of two conditions : the 12‐h ( CPSMP ) intervention group , or the 3‐month wait‐list control group . Self‐report measures of pain‐related and other quality of life variables as well as two hypothesized mediating variables were collected pre‐treatment and 3 months later by assessors blind to group allocation . One hundred and two subjects completed the study . Results of intention‐to‐treat analysis indicated that the treatment group made significant short‐term improvements in pain , dependency , vitality , aspects of role functioning , life satisfaction and in self‐efficacy and re source fulness as compared to the wait‐list control group . Because it has a st and ard protocol , this intervention has the potential to be reliably delivered at low cost in varied urban and rural community setting s and hence be more widely accessible to a greater number of people suffering from chronic pain than is currently the case with more specialized pain clinic services . Based on the results of this study , further research evaluating the long‐term impact and potential cost savings to the individual and to the health care system is warranted & NA ; The current investigation studied the effectiveness of a secondary prevention program for nurses with back pain who were deemed at risk for developing a chronic problem . A 2 × 3 repeated measures design was employed with 2 groups and 3 assessment periods . The treatment group received an intervention design ed to reduce current problems , but above all to prevent reinjury and minor pains from becoming chronic medical problems , and it included a physical and behavioral therapy package . The control group was placed on a waiting‐list . Results indicated that the treatment group had significantly greater improvements than the control group for pain intensity , anxiety , sleep quality and fatigue ratings , observed pain behavior , activities , mood , and helplessness . These differences were generally maintained at the 6 month follow‐up . In addition , the treatment group broke a trend for increasing amounts of pain‐related absenteeism , while the control group did not . Taken as a whole , the results suggest that a secondary prevention program aim ed at altering life style factors may represent an effective method for dealing with musculoskeletal pain problems There is a serious need to provide effective early interventions that prevent the development of persistent pain and disability . Identifying patients at risk for this development is an important step . Our aim was to explore whether distinct subgroups of individuals with similar response patterns on a screening question naire exist . Moreover , the objective was to then relate these groups to future outcomes , for example , sick leave as an impetus for developing tailored interventions that might better prevent chronic problems . A total of 363 patients seeking primary care for acute or subacute spinal pain completed the Örebro Musculoskeletal Pain Screening Question naire  and were then followed to determine outcome . Cluster analysis was used to identify subgroups . Validity was tested using 3 methods including the split-half technique . The subgroups were compared prospect ively on outcome measures obtained 1 year later . Using pain intensity , fear-avoidance beliefs , function , and mood , we found 4 distinct profiles : Fear-Avoidant , Distressed Fear-Avoidant , Low Risk , and Low Risk-Depressed Mood . These 4 subgroups were also robust in all 3 of the validity procedures . The 4 subgroups were clearly related to outcome . Although the low risk profiles had virtually no one developing long-term sick leave , the Fear-Avoidant profile had 35 % and the Distressed Fear-Avoidant profile 62 % developing long-term sick leave . Our results suggest that fear-avoidance and distress are important factors in the development of pain-related disability and may serve as a key for early identification . Providing interventions specific to the factors isolated in the profiles should enhance the prevention of persistent pain and disability & NA ; Chronic pain is a common , disabling problem in older adults .  Pain self‐management training is a multimodal therapy that has been found to be effective in young to middle‐aged adult sample s ; however , few studies have examined the effectiveness of this therapy in older adults . In this r and omized , controlled trial , we evaluated a pain self‐management training group ( SMG ) intervention as compared with an education‐only ( BOOK ) control condition .  Participants , 65 years of age or older who experienced persistent , noncancer pain that limited their activities , were recruited from 43 retirement communities in the Pacific Northwest of the United States . The primary outcome was physical disability , as measured by the Rol and ‐Morris Disability Question naire . Secondary outcomes were depression ( Geriatric Depression Scale ) , pain intensity ( Brief Pain Inventory ) , and pain‐related interference with activities ( Brief Pain Inventory ) . R and omization occurred by facility to minimize cross‐contamination between groups . Two‐hundred and fifty‐six individuals , mean age = 81.8 ( SD : 6.5 ) , enrolled and 218 completed the study . No significant differences in outcomes were found between groups at post‐intervention , 6‐month follow‐up , or 12‐month follow‐up . The SMG group showed a significantly greater increase over time , relative to the BOOK group , in two process measures , as measured by the Chronic Pain Coping Inventory : use of relaxation and use of exercise/stretching . In both cases , the increase was greatest from baseline to the post‐intervention assessment . Study findings indicate that additional research is needed to determine the most effective content and delivery methods for self‐management therapies targeted at older adults with chronic pain AFTER surgical procedures such as amputation , mastectomy , and thoracotomy , as many as 60 % of patients continue to experience pain for at least 6 months , with approximately 10 % reporting severe pain . These chronic postsurgical pain conditions have major adverse effects on health-related quality of life , including physical functioning and emotional well-being . Unfortunately , the efficacy of existing treatments is limited and many patients remain refractory to currently available therapies . For this reason , the development of interventions that prevent chronic pain after surgery has the potential to have a major impact on public health . Substantial attention has been devoted to the hypothesis that the incidence of chronic postsurgical pain can be reduced by “ preventive ” analgesia , and the benefits of preoperative , intraoperative , and postoperative analgesic interventions have been investigated alone and in various combinations . Although the results of these studies suggest that reduced acute pain and analgesic consumption can extend beyond the duration of action of the preventive analgesic interventions , there is little evidence that chronic postsurgical pain can be prevented . Placebocontrolled r and omized clinical trials are needed to determine what specific analgesic interventions are efficacious for preventing chronic pain after what types of surgery for which patients . – 6 A critical component of future clinical trials will involve determining the clinical importance of the benefits of preventive analgesia . The results of recent studies and consensus recommendations provide a foundation for interpreting the benefits of chronic pain treatment ; however , little attention has been paid to determining what magnitudes of chronic pain prevention are clinical ly meaningful . As is true of treatment benefits , evaluating the importance of preventive benefits involves a frequently misunderstood distinction between the interpretation of the clinical importance of individual patient benefits and the interpretation of the clinical importance of group differences . The results of multiple studies have shown that individual patients consider chronic pain reductions of at least 30 % on numerical or visual analog scales to be moderately clinical ly important , whereas reductions of at least 50 % represent substantial improvements . These thresholds are based on ratings by patients of their own improvement at the end of chronic pain trials , and consistent results have been found across different chronic pain conditions and in patients administered active treatments as well as placebo . Criteria for identifying clinical ly meaningful individual improvements are necessary to categorize patients as “ responders ” or “ nonresponders , ” which makes it possible to compare the percentages of patients who achieve clinical ly important outcomes between different treatment and comparison groups . Unfortunately , criteria for determining clinical ly important improvements in patients being treated for chronic pain can not be extrapolated to those undergoing perioperative analgesic interventions to prevent chronic pain . Currently , there are no data that make it possible to determine whether patients who have not experienced chronic pain would consider its prevention after surgery important enough to undergo preoperative , intraoperative , and postoperative analgesic interventions . Evaluations of individual patient improvements associated with chronic pain treatments have emphasized pain reduction , but patients considering the prevention of conditions for which their risk is relatively low can also be expected to be particularly concerned with the adverse effects , safety risks , inconvenience , and costs of the preventive intervention . It is likely that an efficacious preventive analgesia would not completely prevent chronic pain but would instead partially reduce its incidence , intensity , or duration . Such partial preventive benefits would , of course , be even harder for patients to evaluate ; for example , would patients consider reducing pain intensity 6 months after surgery from a daily average of 4 to 2 on a 0–10 scale a clinical ly important benefit ? Would this evaluation change if this reduction in pain intensity at 6 months is known to last for another 2 yr , or if the preventive intervention requires that patients take a medication that causes sedation , nausea , and constipation for 7 days before and 30 days after their operation ? Evaluations of the clinical importance of preventive analgesia must reflect the magnitude of the reductions in chronic pain incidence , intensity , or duration that the intervention would provide . However , even small reductions in the incidence or intensity of a chronic pain condition that can last for months or even years might be considered clinical ly important by patients if Accepted for publication November 17 , 2009 . The authors are not supported by , nor maintain any financial interest in , any commercial activity that may be associated with the topic of this article INTRODUCTION During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain . The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence . Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical , social and occupational factors . METHODS Whereas several review articles regarding the role of psychological risk factors are available up to now , a recently published review conducted by Steven Linton was the first systematic analysis of well controlled prospect i ve studies published since 1967 . Using a grading system similar to that recommended for guidelines the author defined a level A evidence when at least two good- quality prospect i ve studies supported the prospect i ve power of a variable . Level B evidence had support from one prospect i ve study . Level C represented inconclusive data and level D indicated that no studies met the criteria . Based on a literature search of more than 900 studies , 37 good- quality prospect i ve studies were analysed in detail . RESULTS The results indicated level A evidence for the following interrelations : ( 1 ) Psychosocial variables , especially chronic distress in daily life , depression and work dissatisfaction were clearly associated with the onset of back and neck pain ( 2 ) . Psychological variables , especially chronic stress in daily life , work dissatisfaction , depression and pain-related cognitions and coping behaviour were clearly linked to the transition from acute to chronic pain and disability ( 3 ) . Psychological variables generally had more prospect i ve power than biomedical , social or objective occupational variables . Among the pain-related cognitions , catastrophizing and fear-avoidance-beliefs yielded the most empirical support . Among coping behaviour passive coping stretegies such as avoiding behaviour was most important . At least level B evidence has been shown for the counterpart of an extreme suppressive coping behaviour . Patients who tended to suppress or ignore pain in order to finish all activities they started , who were unable to integrate phases of passive relaxation into the daily routine displayed a high risk of chronicity of pain 6 months after an acute phase of pain . One international and two German good- quality prospect i ve studies have shown the predictive power of a maladaptive suppressive behaviour pattern . Based on the avoidance-endurance-model of pain chronification , both extreme and one-sided passive pain coping as well as one-sided suppressive coping modes were conceptualized as maladaptive due to the process of chronicity . We assume that extreme passive behaviour will lead to immobility and muscular atrophy . Neurophysiological processes of sensitization will further lead to the development of chronic pain . On the other h and , extreme suppressive behaviour will lead to an overuse of muscles and joints with a repetitive combination of muscular hyperactivity and pain . These repetitive pain experiences will also elicit neurophysiological processes of sensitization . ( 4 ) Psychosocial variables displayed more predictive power than biomedical or biomechanical factors . ( 5 ) Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability . Mixed empirical evidence has been shown for the role of personality factors ( level C evidence ) and no support has been found for the idea of a " pain prone " personality disorder or for the role of sexual and physical abuse . DISCUSSION 20 years of research , several qualitative review s and a recently published systematic review of 37 good- quality prospect i ve studies regarding the role of psychological , biomedical , social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain . Furthermore , the psychological factors displayed more predictive power than biomedical or biomechanical variables . As a consequence for clinical practice , these psychological risk factors have to be considered as " yellow flags " if a back pain problem wo n't respond to medical treatment for more than four weeks . As a further consequence , special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain . The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group Introduction Internet-delivered psychological interventions among people with chronic pain have the potential to overcome environmental and economic barriers to the provision of evidence -based psychological treatment in the Irish health service context . While the use of internet-delivered cognitive – behavioural therapy programmes has been consistently shown to have small-to-moderate effects in the management of chronic pain , there is a paucity in the research regarding the effectiveness of an internet-delivered Acceptance and Commitment Therapy ( ACT ) programme among people with chronic pain . The current study will compare the clinical -effectiveness and cost-effectiveness of an online ACT intervention with a waitlist control condition in terms of the management of pain-related functional interference among people with chronic pain . Methods and analysis Participants with non-malignant pain that persists for at least 3 months will be r and omised to one of two study conditions . The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period . The control group will be a waiting list group and will be offered the ACT intervention after the 3-month follow-up period . Participants will be assessed preintervention , postintervention and at a 3-month follow-up . The primary outcome will be pain-related functional interference . Secondary outcomes will include : pain intensity , depression , global impression of change , acceptance of chronic pain and quality of life . A qualitative evaluation of the perspectives of the participants regarding the ACT intervention will be completed after the trial . Ethics and dissemination The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Irel and Galway Research Ethics Committee ( 12/05/05 ) . The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer- review ed journals . Trial registration number IS RCT N18166896 Background Unrelieved pain among nursing home ( NH ) residents is a well-documented problem . Attempts have been made to enhance pain management for older adults , including those in NHs . Several evidence -based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults . Despite the proliferation and dissemination of these practice guidelines , research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting . One promising approach is the embedding of guidelines into explicit protocol s and algorithms to enhance decision making . Purpose The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence -based pain assessment and management practice s , decreasing pain and depressive symptoms , and enhancing mobility among NH residents . Methods The study used a cluster-r and omized controlled trial ( RCT ) design in which the individual NH was the unit of r and omization . The Roger ’s Diffusion of Innovations theory provided the framework for the intervention . Outcome measures were surrogate-reported usual pain , self-reported usual and worst pain , and self-reported pain-related interference with activities , depression , and mobility . Results The final sample consisted of 485 NH residents from 27 NHs . The investigators were able to use a staggered enrollment strategy to recruit and retain facilities . The adaptive r and omization procedures were successful in balancing intervention and control sites on key NH characteristics . Several strategies were successfully implemented to enhance the adoption of the algorithm . Limitations /Lessons The investigators encountered several method ological challenges that were inherent to both the design and implementation of the study . The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment . It was difficult to identify valid , reliable , and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report . Another challenge was the inability to incorporate advances in implementation science into the ongoing study Conclusions Method ological challenges are inevitable in the conduct of an RCT . The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study PURPOSE OF THE RESEARCH This paper reports findings from a r and omized controlled pilot study evaluating the PRO-SELF Plus Pain Control Program , a U.S.-developed cancer pain self-management intervention , regarding feasibility and effect sizes in a German patient sample . METHODS AND SAMPLE Thirty-nine German oncology out patients were r and omized to intervention ( n = 19 ) and control ( n = 20 ) groups . The intervention group received the PRO-SELF Plus Pain Control Program in 6 visits and 4 phone calls a 10-week period . The control group received st and ard education and care . The intervention employed three key strategies : information provision , skills building , and nurse coaching . Primary outcomes were changes in average and worst pain intensity . Secondary outcomes included changes in pain-related knowledge , opioid intake , and self-efficacy . Data were collected at enrollment , then at 6 , 10 , 14 , and 22 weeks . KEY RESULTS The group-by-time effect showed a statistically significant increase in knowledge ( week 10 : p = 0.04 ; week 22 : p < 0.01 ) . Despite slight reductions in average and worst pain , no statistically significant changes were found for pain , opioid intake , or self-efficacy . CONCLUSIONS This study is the first to evaluate and demonstrate the feasibility of a U.S.-developed cancer pain self-management intervention in a German patient population .  Pain self-management related knowledge improved significantly and effect sizes for pain reduction were determined . Findings from this pilot RCT provide the basis for planning a larger RCT . CLINICAL TRIAL REGISTRATION NUMBER NCT00920504 & NA ; Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems . Patients ( 198 ) seeking help for acute musculoskeletal pain ( MSP ) , e.g. , back and neck pain participated in two studies of the effects of an Early Active intervention which underscored ‘ well ’ behavior and function compared to a Treatment as Usual control group . The quantity of the Early Active treatment was a median of 1 doctor 's appointment and 3 meetings with a physical therapist .  Study I concerned patients with a prior history of sick‐listing for MSP , while study II involved patients with no prior history of MSP . Treatment satisfaction , pain experience , activities and sickness absenteeism were assessed before , after and at a 12‐month follow‐up . In study I ( patients with a history of MSP ) , the results showed significant improvements for both groups , but virtually no differences between the groups . Similarly , in study II ( no history of MSP ) both groups demonstrated significant improvements e.g. , for pain intensity and activity levels . However , the Early Active treatment result ed in significantly less sick‐listing relative to the control group . Moreover , the risk of developing chronic ( > 200 sick days ) pain was 8 times lower for the Early Activation group . This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for ‘ first‐time ’ sufferers only . Consequently , the content and timing of treatment for pain appear to be crucial . Properly administered early intervention may therefore decrease sick leave and prevent chronic problems , thus saving considerable re sources OBJECTIVE This article describes the rationale , design , and baseline findings from an ongoing study of collaborative care for chronic musculoskeletal pain and comorbid depression . DESIGN Cluster r and omized clinical trial . PARTICIPANTS AND SETTING Forty-two clinicians and 401 patients from five Veterans Affairs primary care clinics . INTERVENTION The intervention was based on the chronic care model , and included patient and provider activation and education , patient assessment , outcomes monitoring , and feedback to providers over 12 months . The intervention team consisted of a full-time psychologist care manager and a part-time physician internist . Approaches included goal setting emphasizing function , patient activation and educating about fear avoidance , and care management . OUTCOME MEASURES Main outcomes are Rol and -Morris Disability Question naire ( RMDQ ) score , depression severity ( Patient Health Question naire-9 ) , and pain severity ( Chronic Pain Grade Severity subscale ) at 6 and 12 months . BASELINE RESULTS Fifteen percent of primary care patients mailed a study advertisement letter requested screening for the study . The mean age of enrolled patients was 62 . Back and neck or joint pain diagnoses were present in 67 % and 65 % of patients , respectively . Mean pain duration was 15 years , and mean RMDQ score ( range 0 - 24 ) was 14.7 ( st and ard deviation = 4.4 ) . Sixty-five percent of patients were receiving disability . Eighteen percent of patients met criteria for major depression , 17 % for posttraumatic stress disorder , and 9 % for alcohol misuse . Thirty-nine percent of patients felt strongly that experiencing pain was a sign of damage , and 60 % reported strong avoidance of painful activities . CONCLUSIONS These baseline data support the rationale to develop a multifaceted approach to treat chronic pain in primary care that includes detection and treatment of psychiatric comorbidity PURPOSE : To determine the effectiveness of a clinical - practice intervention in improving the control of pain in out patients with cancer . METHOD : Between July 5 and September 30 , 1995 , a r and omized , controlled trial of 510 cancer out patients and 13 oncologists was conducted at 23 clinics in Indiana . All the patients completed assessment s of their pain , their pain regimens , and the degrees of relief received ; they were surveyed again by mail four weeks after their clinic visits . The intervention group 's clinical charts contained a summary of the completed pain scales ; the oncologists who treated these patients were instructed to review the summary sheet prior to an evaluation . This summary was not available for the oncologists treating the patients in the control group . Each patient 's pain management index ( PMI ) was calculated : the patient 's pain medication level was rated on a scale of 0 to 3 ; the patients 's pain level was rated on a scale of 0 to 3 and then subtracted from the first rating . A negative PMI was interpreted as representing insufficient treatment . Data were analyzed with several statistical tests . RESULTS : In all , only 320 patients who reported cancer-related pain were used in the analysis : 160 to 260 in the control group and 160 of 250 in the intervention group . The groups were similar with respect to demographics , cancer sites , and performance status . A significant difference ( p = .0162 ) in the physicians ' prescription patterns was found . In the control group , prescriptions for 86 % of the patients did not change , with no decrease in analgesic prescriptions ; for 14 % of the patients analgesic prescriptions increased . In the intervention group , analgesic prescriptions changed for 25 % of the patients , decreasing for 5 % and increasing for 20 % . A decrease in the incidence of pain described as more than life 's usual aches and pains was found for the intervention group ( p = .05 ) . No significant difference was found between the groups for the patients undertreated for pain , as measured by PMIs . CONCLUSION : Although analgesic regimens were altered significantly when the physicians understood more about the patient 's pain , cancer pain management remains a complex problem . Future studies should focus on the long-term systematic incorporation of simple pain- assessment tools into daily outpatient oncology practice s as well as on innovative ways to address other aspects of managing cancer pain Introduction The prevalence of pain in patients with cancer is still too high . Factors relating to ineffective pain treatment fall into three categories : the health care system , professional care providers , and patients . In patients , various barriers lead to noncompliance . Previous educational interventions have increased their knowledge of pain and decreased short-term pain levels . In this r and omized controlled trial , the authors investigated how an intensive home-based education program given by nurses affected short-term and long-term pain levels . Material s and methods One hundred and twenty cancer patients were r and omized to receive either the pain education program ( PEP ) or usual care .  Pain , knowledge , quality of life , anxiety , and depression were measured at baseline and after 4 and 8 weeks . In the intervention group , effects on symptom levels were communicated to the treating physician . Results The level of pain had decreased at 4 weeks , but not at 8 weeks . Significant decreases in pain only persisted in those patients with a high pain score at baseline . Knowledge of pain significantly increased in the intervention group . No correlation was found between increased pain knowledge and decreased pain levels . Conclusions The PEP given by nurses lowered pain intensity levels in cancer patients and increased their knowledge of pain . More attention should be paid to patient education and to communication between patients and health professionals regarding pain and pain management Background Chronic pain is a common and frequently disabling problem in older adults . Clinical guidelines emphasize the need to use multimodal therapies to manage persistent pain in this population . Pain self-management training is a multimodal therapy that has been found to be effective in young to middle-aged adult sample s. This training includes education about pain as well as instruction and practice in several management techniques , including relaxation , physical exercise , modification of negative thoughts , and goal setting . Few studies have examined the effectiveness of this therapy in older adult sample s. Methods / Design This is a r and omized , controlled trial to assess the effectiveness of a pain self-management training group intervention , as compared with an education-only control condition .  Participants are recruited from retirement communities in the Pacific Northwest of the United States and must be 65 years or older and experience persistent , noncancer pain that limits their activities . The primary outcome is physical disability , as measured by the Rol and -Morris Disability Question naire . Secondary outcomes are depression ( Geriatric Depression Scale ) , pain intensity ( Brief Pain Inventory ) , and pain-related interference with activities ( Brief Pain Inventory ) . R and omization occurs by facility to minimize cross-contamination between groups . The target sample size is 273 enrolled , which assuming a 20 % attrition rate at 12 months , will provide us with 84 % power to detect a moderate effect size of .50 for the primary outcome . Discussion Few studies have investigated the effects of multimodal pain self-management training among older adults . This r and omized controlled trial is design ed to assess the efficacy of a pain self-management program that incorporates physical and psychosocial pain coping skills among adults in the mid-old to old-old range Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing
Such interventions would have the potential to reduce the prevalence of chronic pain in the population .
Although certain risk factors can identify individuals who are most likely to develop chronic pain , few interventions to prevent chronic pain have been identified .
To facilitate the identification of preventive interventions , an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain .
We present general design considerations for prevention trials in population s that are at relatively high risk for developing chronic pain .