Background
Multidisciplinary Pain Rehabilitation Programs (PRPs) are recommended to treat patients with chronic musculoskeletal pain (CMP) [
1,
2]. These PRPs, based on the biopsychosocial model, aim to decrease disability and optimize participation of patients with CMP. A systematic review showed that PRPs have a moderate, but consistent, positive effect on disability and pain, compared to usual care or physical treatment programs for patients with chronic low back pain [
3]. PRPs result in better self-management of pain and disability, and a reduction in healthcare utilization in treated patients was found, which may contribute to a decrease of direct and indirect costs over the long term [
4].
Although effective, PRPs are relatively expensive. The multidisciplinary characteristics, as well as the high number of contact hours and total duration of PRP, provide relatively high direct costs and travel expenses for the patients. Dosage of PRP includes the total duration, the total number of contact hours, and intensity of treatment (number of contact hours per week). Differences in the dosage of PRP may lead to differences in direct and indirect costs. Choices for dosage and how dosage is established for an individual patient is unknown. A recent systematic review showed that dosage of PRP has never been studied as a primary aim and the optimum dosage of PRPs is currently unknown [
5]. The studies included in that review differed in terms of dosage (total duration, from weeks to months, and regarding contact hours, from fewer than 10 to over 100 h) and effect.
Better understanding of variables that are taken into account when deciding for a particular dosage could lead to better and more efficient patient care, which will benefit patients, rehabilitation facilities, insurers and employers. This study aimed at exploring perspectives of patients and rehabilitation professionals to acquire insight into factors that may contribute to dose choices of multidisciplinary outpatient PRP. In addition, this study aimed at examining the argumentations underlying choices in dosage of PRPs in three rehabilitation centers in the Netherlands.
Methods
A study using an exploratory qualitative design with thematic analyses was conducted to gain in-depth information about the perspectives of patients and rehabilitation professionals involved in PRPs regarding the dosage of these programs. The study was performed in three rehabilitation centers in the Netherlands. These centers were selected because of their differences in dosage, while patient characteristics of these centers are similar [
6]. Individual semi-structured interviews with patients who had completed a multidisciplinary PRP, as well as focus groups with professionals working in multidisciplinary PRP, were performed. The medical ethics committee of the University Medical Center of Groningen (UMCG) granted a waiver for this study. All participants signed informed consent for participation, digital recording and the use of data.
Participants
A purposive sample of patients was included from three rehabilitation centers in the Netherlands with the task to develop, innovate and evaluate PRPs: Adelante in Hoensbroek (RC1), located in the south; Roessingh in Enschede (RC2), located in the east and the Center of Rehabilitation of the UMCG (RC3), located in the north. The sampling strategy aimed to include patients who completed a PRP, with a range of personal and clinical characteristics: age, disability status, gender, working status, and dosage received. PRP should have been completed for at least two weeks. The second author contacted potential participants (recruited by the contact person of the rehabilitation center) via telephone to check their willingness to participate in the study and to plan the interview. They received written information about the purpose of the interview.
The contact person of the centers selected rehabilitation professionals from the rehabilitation centers. They participated in the focus groups, provided that they were working within the area of multidisciplinary PRP for a minimum of two years, for at least 0.5 fte. We aimed to include rehabilitation professionals from different disciplines involved in PRPs (i.e. occupational therapist/physiotherapist/psychologist/physiatrist). These rehabilitation professionals should be involved in determining the individual dosages of the program for the patient.
Data collection
Data were collected between May and September 2014. A total sample of 15 patients was planned for the interviews, five patients from each rehabilitation center, with the expectation of reaching data saturation. A semi-structured interview scheme was constructed Additional file
1 for patients using open questions enabling reflection about experiences and perceptions on dosage of treatment received. The interview started with questions about the total duration and intensity of PRP, followed by questions regarding personal experiences and perceptions of treatment dosage, such as: “what did you like and dislike about the duration and intensity of the program” and “which factors, in your opinion, influence dosage of PRP?”. Also patients’ opinions regarding the relationship of dosage to return to work and personal and general costs were asked. Face-to-face interviews were performed at the rehabilitation center where the patient was treated. The interviews were scheduled for 60 min and were audio recorded. Prior to this study, an interview was pilot tested, which led to refinements in the setup of the interview and questioning technique.
For the focus group meetings, a minimum of five rehabilitation professionals of different disciplines per center were invited in order to achieve variation in perspectives on PRP dosage per rehabilitation center. Meetings were planned for 90 to 120 min and were audio recorded. An interview scheme was constructed, aiming to gain insight into the line of reasoning underlying dosage choices, as well as rehabilitation professionals’ perspectives on optimum dosage of PRPs.
All patient interviews and focus group meetings in Adelante and Roessingh rehabilitation centers were led by one author (FW), who has over 10 years of experience as an occupational therapist in pain rehabilitation. Because she was closely acquainted with the rehabilitation professionals at UMCG, a psychologist with experience in chronic pain treatment but who was not involved in the treatment of the patients led this focus group. Another author (EB) assisted in all focus groups.
Data analysis
Interviews and focus groups were audio recorded and transcribed verbatim by two authors (FW and EB). Transcripts were imported into ATLAS.ti, version 5.2, to analyze data. Thematic analysis was considered as the appropriate approach for identifying, analyzing and reporting factors related to dosage of PRP [
7]. Because of the lack of evidence regarding dosage of rehabilitation programs, especially for PRP aimed at behavior change [
5], it was not possible to provide a detailed theoretical framework. Initially, both authors conducted the inductive coding of the interviews and a third researcher independently validated the codes. All codes and quotations were re-analyzed, merged, and renamed.Data saturation was assumed when no new themes emerged from a consecutive interview or focus group.
Discussion
As part of an ongoing exploration into factors related to optimizing dosage decisions of PRP, this study provides insight into perspectives of patients and rehabilitation professionals that in- or explicitely feed PRP dosage decisions. Factors important in relation to dosage of PRP were patient related characteristics, treatment related characteristics and external factors. In the patient related factors case complexity from a biopsychosocial perspective was important in determining dosage. Regarding treatment related characteristics, logistics played a role, including referral factors, the format of the program was considered and interactions between patients and professionals were taken into account. As external factors, support from others, costs, traveling distance and injury compensation were taken into account when deciding on dosage. Despite agreements in factors deemed important to establish dosage, the actual dosages differed to a large extent. For example, in general, patients need clarity about their dosage of the PRP at the start of program, but they would like to have the opportunity to adapt the dosage to their individual needs during PRP, in consultation with their rehabilitation professionals. Patients and rehabilitation professionals mentioned that personal characteristics, such as motivation and ability to change, general status of a patient, acceptance, and self-understanding, are taken into account when determining dosage. No explicit reasons for differences in choices of dosage were expressed during the focus groups, which suggests that PRP dosage choices are based on historical grounds, economics, routine and clinical expertise. This, in turn, can be explained from the absence of evidence to guide clinicians [
5]. It seems that each rehabilitation center has its own ‘baseline-dose’, which forms a basis for choices to extend or shorten the PRP while taking into account factors mentioned in this study. These factors were similar between professionals of different centers.
Treatment outcome is the sum of specific and non-specific treatment effects. Specific effects are those effects that are unique for the treatment, for instance increase of grip strength after grip strengthening exercises, or behavioral modification after cognitive behavioural treatment. Non-specific effects are effects that are common for different types of treatments. These effects are related to for instance expectancy of results, a shared biopsychosocial approach in delivering PRP by team members, relationship factors like warmth, encouragement, listening but also to setting of the treatment. The factors mentioned in this study are linked to specific or non-specific effects. Content and format of treatment, and external factors (e.g. direct and indirect costs, investment in future, personal and work factors, support, test results) are factors that are taken into account when deciding for a certain dosage, and influence satisfaction with dosage. These factors could explain part of the differences in choices of the offered PRP dosage. However, the results of this study showed that these factors are not sufficient to explain the difference in dosage between centers.
It is hypothesized that in the absence of evidence regarding dosage of PRP, as mentioned in the focus groups, all rehabilitation centers made different choices regarding dosage. Current choices are in part based on content and dosage at the time of developing the PRP. Over time, dosage was adapted because of changes in society, costs, experiences, and new insights related to content or format of treatment. At present, however, no published evidence can support or refute the choices of dosage and therefore, rehabilitation professionals are not able to rationally choose optimum dosage of PRP.
Strengths and limitations
Analyzing factors associated with dosage using a qualitative method from the perspective of patients and rehabilitation professionals is considered a strength of this study because it is the first study providing an overview of factors related to dosage from patient and professionals’ perspectives. Taking into account three leading PRPs with different dosages and similar content across the Netherlands is a strength because this provides insight into the differences and similarities regarding perspectives of dosage, resulting in similar factors regardless of dosage varieties. Although this study was performed in three centers, it focused solely on centers in the Netherlands, limiting generalization to PRPs performed in other countries. The qualitative nature of this study resulted in perspectives that cannot simply be generalized to all other groups of patients and rehabilitation professionals involved in PRPs. As this was a first and explorative study, many topics were covered and perspectives were raised during the interviews. While this methodology has lead to a broad range of factors that may be considered to decide on an optimum PRP dose, the downside is its lack of depth of these perspectives. Future studies should build on the results of this study to further explore these factors.
Recommendations
This study is an initial exploration of the perspectives of patients and rehabilitation professionals regarding PRP dosage. It resulted in an overview of factors that can be used for future research and clinical practice regarding determining PRP dosage. Clinical practice might be improved by taking these factors into account when contemplating on dosage and making more explicit dosage decisions with a patient, being a mutual decision between professional and patient, geared towards overall success of PRP.
Conclusions
In conclusion, this study shows that, although dosage of PRP differed, patients and rehabilitation professionals mentioned similar themes that influence dose choices: patient related characteristics (case complexity from a biopsychosocial perspective), treatment related characteristics (logistics and format of the program, interaction between patients and professionals), and external factors (support from others, costs, traveling distance and injury compensation). In absence of published evidence, differences in choices of PRP dosage appear mainly based on historical grounds and clinical expertise. Therefore, research is needed to guide choices of optimum PRP dosage.
Acknowledgements
The authors would like to thank all patients and rehabilitation professionals who participated in the interviews and focus groups at all three rehabilitation centers. They also extend their appreciation to Ernst Schrier for leading the focus group and Annemieke de Jong and Suzanne Broekema for their support with data analysis.