Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain: a Rapid Evidence Review

Abstract

Background: Primary care providers (PCPs) face many system- and patient-level challenges in providing multimodal care for patients with complex chronic pain as recommended in some pain management guidelines. Several models have been developed to improve the delivery of multimodal chronic pain care. These models vary in their key components, and work is needed to identify which have the strongest evidence of clinically-important improvements in pain and function. Our objective was to determine which primary care-based multimodal chronic pain care models provide clinically relevant benefits, define key elements of these models, and identify patients who are most likely to benefit.

Methods: To identify studies, we searched MEDLINE® (1996 to October 2016), CINAHL, reference lists, and numerous other sources and consulted with experts. We used predefined criteria for study selection, data abstraction, internal validity assessment, and strength of evidence grading.

Results: We identified nine models, evaluated in mostly randomized controlled trials (RCTs). The RCTs included 3816 individuals primarily from the USA. The most common pain location was the back. Five models primarily coupling a decision-support component-most commonly algorithm-guided treatment and/or stepped care-with proactive ongoing treatment monitoring have the best evidence of providing clinically relevant improvement in pain intensity and pain-related function over 9 to 12 months (NNT range, 4 to 13) and variable improvement in quality of life, depression, anxiety, and sleep. The strength of the evidence was generally low, as each model was only supported by a single RCT with imprecise findings.

Discussion: Multimodal chronic pain care delivery models coupling decision support with proactive treatment monitoring consistently provide clinically relevant improvement in pain and function. Wider implementation of these models should be accompanied by further evaluation of clinical and implementation effectiveness.

Keywords: chronic pain; multidisciplinary; multimodal; musculoskeletal pain; rapid review.

Fig. 1

Literature flowchart.

Fig. 2

Risk of bias assessment of included RCTs.

Fig. 3

Forest plot: improvement in pain and pain-related function. Measured by Roland-Morris Disability Questionnaire. †Measured by Brief Pain Inventory, ‡Rate of improvement for model vs usual care. Abbreviations: ESCAPE = Evaluation of Stepped Care for Chronic Pain; NNT = number needed to treat; NR = not reported; RCT = randomized controlled trial; RB = relative benefit; SEACAP = Study of the Effectiveness of a Collaborative Approach to Pain; STarT Back = stratified primary care management for low back pain; SCAMP = Stepped Care for Affective Disorders and Musculoskeletal Pain; SCOPE = Stepped Care to Optimize Pain Care Effectiveness.